Forms

Patient Forms

For your convenience we have placed our office forms on line for your review or use. You may choose to open these forms using Microsoft Word or Adobe Acrobat. For the first visit, please complete our Registration Form and either bring it with you to the first appointment or e-mail it to us. Please complete all sections of the Registration Form which includes:

1. Registration and Insurance Information
2. Dental and Medical History
3. Confidentiality Statement
4. Consent and Release
5. Financial Policy
6. Acknowledgement of Receipt of Notice of Privacy Practices
Please also review our Notice of Privacy Practices prior to completing #6 above.

If you are transferring your child’s care to our office from another dental provider, please complete the “Authorization to Release Records To” form. If you are an existing patient leaving the area or transferring care to another dental provider, please complete the “Authorization to Release Records From” form. These forms allow us to either request or transfer your records.

Existing Patients

PATIENT LOGIN

On-Line Patient Forms
New Patient Registration Form with Financial Policy

NEW PATIENT QUESTIONAIRES

Patient Forms, Download and Print
Registration Form with Financial Policy
Notice of Privacy Practices
Medical History Update
Authorization to Release Records to Pima Pediatric
Authorization to Release Records from Pima Pediatric
Financial Policy

Pre Treatment/ Operative Forms

What to Expect Before and After Oral Conscious Sedation
Restorative Material Information Sheet
Informed Consent for Dental Treatment
Informed Consent – Oral Conscious Sedation

Post Treatment/Operative Forms

Post-operative instructions for Dental Treatment
Post-operative Instructions after Extractions
Post-operative Instructions for General Anesthesia
Post-operative instructions for Oral Conscious Sedation