Online Forms

WARNING: This is a demo of a website for a fictitious medical practice. It was created for illustration purposes only, to demonstrate options for a website design and possible approaches

As a new patient, we want you to feel welcome. In order for us to serve you as best as possible, we will review your medical and dental history, questions, and concerns together

Please fill out our secure online patient information form to the best of your ability. If you have any questions, please contact our office and we will be happy to assist you

If you are an existing patient, to make sure that we have all your information up-to-date, please take a moment to update your contact information and communication preferences

Other Forms

You may download and print out HIPAA Privacy Notice and HIPAA Privacy Acknowledgment
To obtain or to arrange to see a copy of your medical records, or to share your medical records with your contact, please submit the following form: 'Authorization to Release Medical Records'
To restrict disclosure of your information to a health plan, please submit the following form: 'Restriction of Disclosure of Information to a Health Plan'
To submit a complaint or concern about HIPAA Compliance, please fill out the following form: 'Complaint about HIPAA Compliance'
To obtain an accounting of disclosures of your health information, please submit the following form: 'Accounting of Disclosures'

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