Adult Patient Form

Patient Information

Spouse / Partner Information

Emergency Contact Information

Dental Insurance Information

Primary Insurance
Secondary Insurance

Dental History

Medical History


I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.

Acknowledgement of Privacy Practices

My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996(HIPAA).I understand that this information can and will be used to:

  • Provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly.
  • Obtain payment from third-party payers for my health care services.
  • Conduct normal health care operations such as quality assessments and improvement activities.

I have been informed of my dental provider’s NOTICE OF PRIVACY PRACTICES containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such NOTICE OF PRIVACY PRACTICES. I may contact this office at the address above to obtain a current copy of the NOTICE OF PRIVACY PRACTICES.

I understand that I may request in writing that you restrict how my private information is used of, disclosed to carry out treatment, payment or health care operations and I understand that you are not required to agree to my required restrictions, but if you do agree, then you are to abide by such restrictions.