New Patients

Forms
6/1/2017
Patient Registration Form

The patient registration form is what we will use for any new patients in order to capture all neceseray patient information.

6/1/2017
Authorization Form

The authorization form is a required document in order for us to gain permission to render treatments and contact your insurance company.

6/1/2017
Medical/Dental Questionnaire

The medical/dental questionnaire will make it possible for us to be more successful and thorough in your treatment. It aims to capture some of your medical and dental history. Your answers are for our records only and will be confidential.

2013-2018
Notice of Privacy Practices

This notice describes how health informations about you may be used and disclosed and how you can get access to this information. Please carefully review it.

2003-2018
Notice of Privacy Practices - Patient Acknowledgement and Consent Form

This Notice of Privacy Practices contains the information that HIPAA requires us to disclose regarding our privacy practices.

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Copyright ©2017: Hagan Rodriguez Perio