Patient Forms

You can download our patient forms by clicking this button, or quickly fill out our forms online below.

New Patient Forms

Patient Health History

MF

YESNO

YESNO

YESNO

Please mark YES if your child has a history of any of the following conditions. For each “YES”, provide details in the box as the bottom of this list.
Mark NO if the condition does not apply to your child.

YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO

By signing I affirm that all the information given is to my best knowledge. It will be held in the strictest confidence and I understand it is my responsibility to inform the office of any changes regarding my child’s health history.


Patient Information

MALEFEMALE


PARENT/GUARDIAN INFORMATION

YESNO


DENTAL HISTORY

Does your child have a history of the following? For each YES response, please describe:

YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO

YESNO

YESNO


PATIENT HIPAA CONSENT FORM

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

  • Treatment (including direct or indirect treatment by other healthcare providers involves in my
    treatment)
  • Obtaining payment from third party payers (e.g. my insurance company)

I have also been informed of and given the right to review a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my information is used and disclosed to carry out treatment or pay the health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction

I understand that I may revoke this consent, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.