In an effort to make your first appointment go as smoothly as possible, we ask that you please print the following forms, complete them in their entirety and bring them with you to your appointment. Also, be sure to bring your insurance card(s) and photo I.D. with you!
If you will be transferring your records from your previous dentist, please print the request form and fill it out. You may take it to your previous dentist and have your records sent to us at frontdesk@dickeydental.com or please email it to us prior to your visit and we will request them for you.
- Patient Registration
- Medical & Dental History
- Notice of Privacy Practices
- Authorization for Release of Information
- Authorization to Release Health Information
- Acknowledgement of Receipt Of Notice of Privacy Practices
- Local Anes Informed Consent
- Opt in for email text
- Release of Records
- Signature on File for Insurance
