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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.

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 – Transfer Patients:

• 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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