Home  / Patient Resources  / Forms and Documents

Library of frequently accessed forms

PATIENT REGISTRATION AND ACCOUNT UPDATE FORMS
Personal Information Update Demographic, contact and insurance information update.
Patient Agreement Consent for diagnostic services, dental and financial agreement and general terms of service.
Cancellation Policy Our remarkably simple and accommodating cancellation policy.
Medical History Update Listing of patient's current medical conditions. This form is updated at each visit.
HIPAA Notice of Privacy Practices Our disclosure on how we use your information and summary of your rights to privacy of information provided to us.
HIPAA Consent of Information Disclosure Designate individuals such as family members to access your health information stored with us.
X Ray Transfer Requirements Important information regarding transferring your x rays from other dental providers.
MISCELLANEOUS FORMS
Medical Clearance Are you undergoing pregnancy, medical treatment or are you under cardiologist care? Please ask your physician to let us know if you require special accommodations before undergoing treatment in our office.
Orthodontic Treatment Clearance Are you starting your orthodontic treatment with us? Please ask your dentist fill out this form to help us evaluate your general dental conditions!
Previous Periodontal Treatment Attestation Are you transferring your ongoing periodontal treatment to us? Please fill out this form so that we can work with your insurance to request coverage for periodontal services done in our office.
Designation of guardianship
Date of prior placement of prosthesis
ACH Payment Plan Authorization
Credit Card Payment Plan Authorization (Orthodontic Treatment Only)
Dental Record Transfer Authorization
TREATMENT CONSENT FORMS
Orthodontic Treatment Consent