Patient Forms

Patient Resources

Current and New Patient Resources & Forms

We have made our new patient forms available to you as Adobe Acrobat files. For your convenience, we recommend printing and completing these forms at home. Please remember to bring your completed forms with you to your first appointment. If you have any problem getting these files to print properly, call our office and we will gladly send or fax them to you.

New Patient Form Notice of Privacy Practices

Acknowledgement of Receipt of Dale Family Dental NOTICE OF PRIVACY PRACTICES

Free Text

Acknowledgement of Receipt of Dale Family Dental

NOTICE OF PRIVACY PRACTICES

Acknowledgement

I acknowledge that I have received from Dale family Dental a copy of the NOTICE OF PRIVACY PRACTICE as required by Federal Law.

Name

Date

Free Text

FOR DALE FAMILY DENTAL USE ONLY

We attempted to obtain written acknowledgement of receipt of our notice privacy practice, but acknowledgement could not be obtained because:

Patient refused to sign

Communication barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Other (Please Specify)

Other

Financing

If you want to enhance your smile with cosmetic dentistry or need restorative procedures, you don't want money to stand in your way. Our dental office has partnered with CareCredit, a trusted name in patient financing, to bring you dentistry that fits your budget. Click here to be pre-approved for CareCredit financing.