Patient Forms

We know no one likes to read through the fine details and that’s why we’re quickly going over what each form means and why it’s necessary. Before you start filling out these forms, please know that each one is written with the purpose of creating clearer communication between the patient and the practice. Our intention is to keep you informed with these dental patient forms:

New Patient Registration 

The new patient paperwork goes over the basic information we need to know prior to your first appointment. This includes a record of your name, contact info and other personal identification, along with your insurance provider, emergency contact number and past medical/dental history.

By signing, you authorize that you understand and accept your rights as a patient along with the terms necessary for treatment listed throughout these forms.

X-Ray Release Form

The purpose of this form is to give patient permission for sending private dental records. By signing this, you authorize and request the release of personal X-rays by either digital or paper means to the provided patient’s address or a decided upon dental office.

Practice Policies 

This form outlines our practice policies and its completion signifies your clear understanding of these policies, including a patient’s financial responsibility and medical rights. If anything is unclear, a member of our staff will be happy to discuss any questions over the content of these forms.

All forms must be completed before being seen by a licensed dentist. This includes new patient registration forms, financial agreements and other applicable documents.

Our practice offers care for both adults and minors. We also provide insurance billing for our patients. We accept cash, checks, most credit cards and CareCredit® for payment. Patients are responsible for payment in full at time of service.

HIPAA Communication Form

HIPAA is the Health Insurance Portability and Accountability Act and it protects your health information. This form’s purpose is to let you know how your personal information is being shared and what measures are being taken to keep it private and secure by federal law.

When it comes to what can and can’t be shared from a patient’s identifiable information, the rules are there to protect your privacy as well as your right to accessing your own individual medical information.

Our practice takes patient privacy seriously and these policies exist to keep patient health information confidential, whether on paper or electronically. We won’t disclose such information without your consent or written authorization unless otherwise required by federal or state privacy laws. This form goes over patient communication preferences, including who you approve to receive information concerning your care and how you’d prefer to be contacted.