Forms
Registration Forms for New Patients
A six page PDF containing the following five forms:
- Registration (two pages)
- Office Policies
- Notice to Insured Patients
- Authorization for Release of Information to Family and/or Friends
- Acknowledgement of Receipt of Notice of Privacy Practices.
A six page PDF containing the following five forms:
- Registration (two pages)
- Office Policies
- Notice to Insured Patients
- Authorization for Release of Information to Family and/or Friends
- Acknowledgement of Receipt of Notice of Privacy Practices.
Parental Authorization for Routine Dental Care
This form must be filled out and submitted prior to treating patients under the age of 18.
This form must be filled out and submitted prior to treating patients under the age of 18.
Permission to Disclose or Obtain Confidential Information
Use this form to request your patient records from Cedar Pearl Dentistry.
Use this form to request your patient records from Cedar Pearl Dentistry.
Oral and Maxillofacial Surgery for Patients Who Have Received Bisphosphonate Drugs
This form is to be completed if you have received Bisphosphonate Drugs, such as: Zometa, Aredia, Fosamax, or Actonel.
This form is to be completed if you have received Bisphosphonate Drugs, such as: Zometa, Aredia, Fosamax, or Actonel.
Refusal of Dental Treatment
This form is to be completed if you wish to opt out of recommended dental treatment.
This form is to be completed if you wish to opt out of recommended dental treatment.
Restorative Dentistry
This form is required for all restorative dentistry procedures.
This form is required for all restorative dentistry procedures.
Root Canal Treatment
This form is required if our office will perform a root canal procedure.
This form is required if our office will perform a root canal procedure.