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New Patient Registration Forms

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Please feel free to download and fill out these forms prior to your first appointment.  If you will be using dental insurance, please also fill out the last two forms, too.  This will help us to better serve you when you arrive!
*after printing the form hit back on your browser to return to our site*

New Patient History

Financial Policy Letter

HIPAA Consent Form

HIPPA Acknowledgement Form

HIPAA notice of Privacy Practices

If you plan to use dental insurance, please also download and fill out these forms:

Insurance Information Letter

Signature on File

Lernor Family Dental * 4747 E Bell Road Suite 7 * Phoenix, AZ * USA * 85032
Phone: (602) 485-4747 Fax: (602) 485-0123

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