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Patient Information

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Insurance Information

“We make every effort to provide you with the finest surgical care and the most convenient financial options. We work with your insurance company to maximize reimbursement for covered procedures. We accept many insurance plans, please call to determine participation with your current plan.”

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New Patient Forms

NEW PATIENT

Demographic Form

(Adult)

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

NEW PATIENT

Demographic Form

(Under 18)

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

NEW PATIENT

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.

NEW PATIENT

Financial Policy

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

NEW PATIENT

HIIPA

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.

NEW PATIENT

Sedation Information

The Sedation Information Form details of basic information about the risks of an operation for our patients.

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Pre/Post Operative Care

PRE OPERATIVE CARE

Recommended Pre-Purchase Grocery List

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

PRE OPERATIVE CARE

Pre-Anesthesia

Instructions

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

POST OPERATIVE CARE

Post-Operative

Instructions

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

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Other Forms

NEW PATIENT

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.


Fax:

(720) 870-1456

Address:

6240 S. Main Street, Suite 255

Aurora, CO 80016