Patrick Palma, DMD | New Patient Forms in Mingo Junction

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Dr. Patrick A. Palma

Family & Cosmetic Dentistry

(740) - 535 - 0600


New Patient Forms

 Below are links to the forms that you need to complete and to bring to our office when you come in for your initial appointment.

For adults;

..... please print out the Patient Registration Form and the Medical History Form, complete these two documents and bring them with you.

For children ( 16 years and under );

..... please print out the Children's Registration Form and complete this document and bring it with you, when you bring your child to our office for his or her appointment.

 

The Privacy Policy Form, describes how we protect your private information and how we use and/or need this information to treat you properly. This is also commonly known as the HIPPA policy law. You can print this out and read it at your convenience. We also have copies of this at our office.

 

Please remember to also bring with you any Insurance Cards or Insurance Forms showing your active coverage.

If you have any questions, about any of these forms or anything else, please let us know.    Thank you.

 

Privacy Policy Form.

Patient Registration Form

Medical History

Children's Registration Form

 

           This forms are  pdf documents which requires the Adobe Reader software.

You most likely already have this software on your computer. However, if you have difficulty reading the notice, please click here to install Acrobat Reader


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Please do not submit any Protected Health Information (PHI).