New Patient Forms

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New Pediatric Dental Patient Forms:

Please complete a copy of our Health History Form and bring it with you to your appointment.

Pediatric Dental Health History Form

Privacy Statement (HIPAA)

Also — if your child has been seen by another dentist, please contact that office (at least two weeks in advance) and request that your child’s x-rays and dental history be sent to us. This will not only provide us with important information but could also avoid duplication of x-rays for your child and help minimize your costs.

If someone other than the child’s legal guardian will be bringing them to their appointments, please complete the “Authorization to Accompany a Minor” consent form below.

 

New Orthodontic Patient Forms:

Please complete a copy of our Health History Form and bring it with you to your appointment.

Ortho Health History – Child

Orthodontic Health History – Adult

Privacy Statement (HIPAA)

 

Consent Forms:

Authorization to Accompany a Minor (If someone other than legal guardian will be bringing patient to appointment)

Consent to Release Information to Durham PDO (Send to Your Current Dentist)

Consent to Allow Durham PDO to Release Patient Information to Another Dental/Medical Office 

 

Referring Dr. Forms:

   Doctor Referral Form

 New Patient Forms

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