AFDPA Online Form

Thank you for choosing our office for your dental needs.

Please take a few minutes to complete this confidential questionnaire so we may better serve you.

  • Please present insurance card to receptionist.
  • Your Smile

  • On a scale of 0-10 with 10 being the highest:

  • YOUR VISIT TODAY

  • HEALTH HISTORY

  • It is IMPORTANT that we know about your Medical/Dental History. These facts have a direct bearing on your dental health.
  • FOR WOMEN ONY

  • PHYSICIANS INFORMATION

  • Do you, or have you ever had any of the following symptoms?

  • Are you allergic or have you reacted adversely to any of the following medications? If so, please check box(s).

  • Please check box(s) of any of the following which you have had or have at present:

  • Please check box(s) If you have a family history of any of the following:

  • Signature accepted as typed version*
  • NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

  • I understand that, under HIPAA, I have certain rights to privacy regarding my potential health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment among healthcare providers involved in that treatment,directly or indirectly. Obtain payment from third-party payers. Conduct normal healthcare operations. I have had the opportunity to read the complete Notice of Privacy Practices. I understand that changes to notice of Privacy Practices may occur and that I may contact this organization to obtain a current copy. I understand that I may request in writing that you restrict how information is disclosed.
  • Signature accepted as typed version*