Human Services

Dental Forms

For your convenience, there are links here to forms that you may wish to fill out and print prior to your dental appointment. To complete the forms, click the link to open the file, then fill out and print the form to sign it. If you do not have access to a printer, we ask that you please come 15 minutes prior to your scheduled appointment time to complete the necessary forms.

Personal Information and Health History (click for form)
This form should be completed by all new patients, and also must be updated by existing patients every two years. It is also requested that you complete a new health history form if there have been significant changes to your health or medications.

Authorization to Release Dental Information (click for form)
This is the form required if you are requesting that our clinic releases your dental record information, such as radiographs, treatment records, and dental charting to another provider. It can also be completed if you would like that information to be sent from another clinic to ours. If you are transferring care from one dental clinic to another, for example, this form is required to have the pertinent information released to the clinic you request.

Authorization for Use or Disclosure of Protected Health Information (click for form)
If you are 18 years of age or older, and would like to give permission to another adult, such as a parent or a spouse, to speak with your dental provider regarding your treatment, this form must be completed. As an adult, your health information is protected by privacy policies. This form allows our clinic to discuss appointment and dental treatment information with another adult if you request it.