Patient Forms

Forms

Once an appointment is made, all patients please complete the health history form below. This will need to be completed before your first visit. It is important to fully complete these forms including the mailing addresses of your doctors and dentists.

TMJ/facial pain patients, please download the TMJ/Facial Pain Consent Form. This will need to be completed and faxed to 301-530-8572, mailed, or brought to your first visit.

Sleep patients, please download the Sleep Consent Form. This will need to be completed and faxed to 301-530-8572, mailed, or brought to your first visit.

We request that all patients can either download or just read our NOTICE OF PRIVACY PRACTICES. At the end of our consent form, we ask you to sign where indicated that you acknowledge having been given the opportunity to review it.

TMJ/Facial Pain Consent Form > Click to download

Sleep Apnea Consent Form > Click to download

Notice of Privacy Practices > Click to download

Billing Procedures > Click to download

CPAP Intolerance Affidavit > Click to download

Epworth Sleepiness Scale> Click to download

Personal Representative Access to Information > Click to download

All forms require Adobe Reader to print. Most computers already have this program installed, but if yours does not Adobe Reader is a free download available at http://get.adobe.com/reader/.

REGISTRATION – HEALTH HISTORY FORM

Step 1 of 14

Name*
First Middle Last
Pronouns
Today's Date
MM slash DD slash YYYY
Date of Birth*
Height
Weight
Address*
Street Address City State ZIP Code
Mobile Phone Number*
Other Phone Number*
Email*
How did you find us?
- Doctor Referral
- Found us on the internet
- Other
If other, please describe below:

REGISTRATION – HEALTH HISTORY FORM

Step 1 of 14

We Are Here to Help You

(301) 530-8570