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Dental Documents

Below are various forms that we will need to perform the highest quality of performance towards your dental and overall health. Please download, print, and fill out each form completely and truthfully. All information provided to us by these forms are protected under the Health Insurance Portability and Accountability Act (HIPPA).

Once you have completed each form, you may fax it to our office at (713) 464 - 1552. We do require you bring the original completed form with you at your first appointment, and when required to update information. If you have any question regarding any of the forms or their content, please call us at the number provided.

Before we can render any service, all patients are required to complete a Health History form and turn it in before or at their first appointment. This document is used to gather the following information:

    • Basic patient information
    • Dental Insurance
    • Emergency contact information
    • Current dental need(s)
    • General dental/medical questionaire

Health History Form
HIPAA Notice of Privacy Practices

HIPAA Consent
HIPAA Authorization for Disclosure
HIPAA Acknowledgement of Receipt