The following patient registration forms can be downloaded to your computer, printed, and completed in the privacy of your home. In order to provide a complete and comprehensive examination, consultation, and treatment plan, it is important to review all your medical information, including medications you take.
Please be prepared to provide this information to our office along with your current dental insurance information so that we may use our expertise to assist you in maximizing your dental benefits. Below is a link to our patient registration forms. If you have any questions about these forms, our staff will assist you with your questions on the day of your visit.
Effective May 1, 2016
First State Dental designates Karen Coho as:
- The Privacy Official, responsible for developing and implementing the dental practice’s privacy policies and procedures, and as the person responsible for:
- receiving complaints
- providing further information about the Notice of Privacy Practices (for example, to patients, staff, etc.), and
- receiving and processing:
- requests for access
- accountings of disclosures
- requests for amendment
NEW PATIENT FORMS
Patient Registration and Dental History Forms- HIPAA - Acknowledgment of Receipt of Notice of Privacy Practices
- HIPAA - Notice of Privacy Practices
- Financial Responsibility Policy
- Transfer of Records Release
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You need free Acrobat Reader to open the download-able forms and documents.
If you do not have a copy of Acrobat Reader you can get one for free by clicking on the icon 'Get Acrobat® Reader'. This will take you to Adobe’s website and enable you to download the Acrobat program to your computer.