New Patient Forms

If you are a new member of the Distinguished Dental family, there are some required forms that you need to complete. If you choose to do so, you may complete the forms in the office on the day of your appointment - we just ask that you arrive 15 minutes early to give yourself enough time to complete the forms before your appointment time. However, you may choose to complete the forms ahead of time. As a convenience to our patients, we offer these forms online so that you can print, fill out, and bring the forms with you to your appointment, which will save you time in the office.

Please find below the forms that we need each new patient to complete:

New Patient Registration Form

The New Patient Registration Form provides the basic information that we need in order to set you up as a new patient. Information includes name, address, phone number, email, insurance information (if you have dental insurance), etc. If you are a parent or legal guardian who is bringing in a minor for dental care, please complete a form for the minor.

New Patient Registration Form (pdf)

New Patient Medical History Form

The New Patient Medical History Form provides Dr. McIntosh with the medical information that she needs to have in order to begin treatment for a new patient. Because health history plays a vital role in achieving and maintaining good oral health, please be as detailed and thorough as possible. If you have any specific questions about this form, please do not hesitate to contact us.

New Patient Medical History Form (pdf)

HIPPA Notice of Privacy Policy and Acknowledgement of HIPPA

Distinguished Dental is dedicated to protecting the privacy of our patients' personal health information. Part of that dedication is complying with the Privacy Rule contained in the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which requires Distinguished Dental to take additional measures to protect patient's information and to inform our patients about those measures.

The HIPPA Notice of Privacy Practices describes how Distinguished Dental may use and disclose a patient's personal health information. Please download and read this information (this one document you do not have to print and bring to your appointment).

HIPPA Polices (pdf)

The Acknowledgement of HIPPA form is simply to record that Distinguished Dental provided you with information on the Privacy Policy.

HIPPA Acknowledgment (pdf)

Distinguished Dental Insurance and Financial Policy

Distinguished Dental is committed to helping our patients completely understand all aspects of their dental treatment, including the financial ones. The Distinguished Dental Insurance and Financial Policy form contains important information that patients need to know about their insurance benefits (if you have insurance) and about Distinguished Dental's policies on payment for services performed.

Insurance and Financial Policy (pdf)

Lighthouse 360 (pdf)