 |  | Patient Forms |
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Please utilize the form links below, to help
save time at check-in or to inform us of changes between your dental
visits. Each form will be sent to the appropriate staff member, please
allow at least 48 hours for to handle your changes. If you have an
appointment within 24 hours of completing one of these forms, please
call or email our Receptionist and alert her of the new information you sent, so
it can be handled before you arrive.
Privacy Policies - this pdf file allows you to view or print our
office privacy policies.
New Patient Initial Paperwork - this form is to be completed BEFORE
your first visit to our office.
Patient Update Form - use this form to change addresses, phone
numbers, email addresses, and/or to move yourself off of an account onto
your own account.
Medical History Update Form - use this form to update your medical
history, we require a full update every 18 months and require patients
to verify or update their medical history every year. However, since we
are currently updating patient information to a new computer system, if
you have not completed a full medical history since July 1, 2011, you
will need to do so at your next appoitment - or use this form now.
New Insurance Form - if you have insurance for
the first time OR a different insurance plan than your last visit, use
this form to provide us the new information before your next
appointment.
Privacy Release for Individuals - if you are 18 or over and you
would like to allow our staff to discuss your information with another
person (ex. parents, guardians, or significant others) please complete
this form. This form is required if you are on the account of
another person or using another person's insurance whom you are not the
married to (ex. adults on their parents' account or using their parents'
insurance). This form allows us to speak with and send information
to those you specify, so we can discuss your care, dental needs,
insurance and billing with others.
Other forms - Surveys:
It is important to us to continually maintain and improve the services we provide to our patients. In order to achieve this, it is vital to receive input from our patients.
The menu to the left contains the current surveys you can take to tell us what you think and below is a description of the purpose for each of these surveys.
Patient Quality Control Survey
This survey is for patients to complete regarding their last appointment(s) in our office. The responses from this survey help to insure we are doing all that we can to provide friendly and high quality care and individual service to our patients. Instead of mailing these surveys to patients, as we have done in the past, now you can complete the survey on our website. Questions with a * are required to complete the survey, others are optional. Your name and email are optional, you may take the survey without completing this information; however, if there is something you wish us to contact you about, then this information is needed.
Website Survey
This survey is to help us continually improve the information and resources we are providing on our website. We appreciate you sharing your thoughts about the ease of use
of our webpages and any suggestions for information you would like to see added to our website. While we do have more planned to improve our site, perhaps we have not yet thought of the idea you have, so please help us to make a better site for your use. |
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