School of Dental Medicine
Patient Care

Patient Registration Forms

Patient Registration Policy
(Includes: Patient Appointment Agreement, Financial Policy, General Policies and Initial Consent, Patient Rights and Responsibilities, and Notice of Privacy Practices)

Patient Consent to Policies
(Agreement that patient signs, acknowledging their agreement of the Patient Registration Policies above)

Easy Markit Confirmation Contract
(Agreement that patient signs, acknowledging their enrollment in Electronic Appointment Verification)

Demographic Image Information Consent
(Agreement that patient signs, acknowledging demographic information and allowing use of data for research and education)

Patient Information Form
Patient Demographic & Information Form

X-ray request
Requesting x-rays from other dental offices.

Parental/Legal Guardian Consent to Allow Treatment of a Minor Child

Pediatric Medical History