Patient Registration Forms
Patient Registration and Health History
You may pre-register with our office by filling out our secure online Patient Registration Form. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information. On your first visit to our office, we will have your completed form available for your signature. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.
If you would prefer a printable Patient Registration Form that you may email or fax to us, you may download it HERE.
Pre-Medication Antibiotic Disclosure
The American Heart Association (AHA) now recommends that prophylactic antibiotic use be reserved for those patients who would have the worst outcomes if IE (Infectious endocarditis) were contracted, such as patients with artificial heart valves, a history of endocarditis, certain serious congenital heart conditions and heart transplant patients who develop a problem with a heart valve. In light of these findings, we are requesting that patients who have previously been required to take antibiotics prior to dental procedures complete this form.
You can also download the printable Pre-Medication Antibiotic Disclosure Form so that you may email or fax to us. It can be downloaded HERE.
Bisphosphonate/Bone Density Medication Disclosure
With the increased frequency of bisphosphonate use for the treatment of osteoporosis, dentists have been alerted to the possibility of osteonecrosis of the jaw related to these drugs. It is important for our office to know if you are on one of these medications or have taken them in the past. If you have been on a bisphosphonate medication, please alert the office on this form and we will discuss the information that we know that may affect your treatment.
Please download the printable Bone Density Medication Disclosure Form so that you may email or fax it to us. It can be downloaded HERE.
The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.
Click HERE to download a copy of our office Privacy Practices.
Acknowledgment of Receipt of Notice of Privacy Practices / HIPAA Non-Secure Communication Consent Form / PHI Limited Authorization & Release
Please fill out the following form to acknowledge that you have reviewed our Privacy Practices and your permission on the HIPAA compliant limited use of your information for office use.
Please download the printable Privacy Practices/HIPAA Acknowledgement Form so that you may email or fax it to us. It can be downloaded HERE.