Forms

New Patient Forms

pdf2   Demographic Form (Adult)

New patient form that needs to be completed prior to service/s for adults.

 

pdf2   Demographic Form (Under 18)

New patient form that needs to be completed prior to service/s for anyone under the age of 18

 

pdf2   Health History

The Health History form is designed to determine any potential risk to our patients before any procedures are done. This would include allergies, medication taken, heart conditions, and any other possible conditions that may of concern to the office staff.

 

pdf2   Financial Policy

The Financial Policy details of basic policy, fees, and any other financial acknowledgements for our patients.

 

pdf2   HIPAA

The HIPAA privacy notification document is designed to inform our patients of their rights to privacy and to ensure you that we take every measure to uphold and protect your personal information.

 

pdf2   Sedation Information

Pre/Post – Operative Care

pdf2   Recommended Pre-Purchase Grocery List

We have a list of recommended inexpensive items that can be purchased to assist with the healing process.

 

pdf2   Pre-Anesthesia Instructions

The following document includes general instruction of Anesthesia, requirements, and any other recommendations before a procedure

 

pdf2   Post-Operative Instructions

This document outlines steps that you should take after surgery for proper care and expedite healing.

Other Forms

pdf2   Health Care Release Form

The Authorization to Release Health Care Information form is an acknowledgement and agreement to release health care information in care of Randall J Russell DDS.