HIPAA Privacy Form
Download this form, print it out, and sign the
necessary lines.  If you have any dental insurance
benefit, don't forget to bring that information with
you also.  This will ensure an efficient registration.
Patient Medical History Form
You can fill in the information by typing on the lines,
checking the boxes, then printing it out.   Or, you can print
it out and fill it in by hand.   Then bring in this form and
the HIPAA form below to speed up your registration.
The Following  Forms Require Adobe Acrobat Reader to View and Print.
Post-Operative Instructions for
Tooth Extraction
If you or a family member has had a tooth removed,
please follow this form's instructions for optimum healing.
Tooth Whitening Instructions
If you or a family member has received an
Opalescence tooth whitening kit from our office,
please follow these instructions for its use.
Post-Operative Instructions for Fillings
If you or a family member has recently received one or more
fillings at our office, please follow these instructions to ensure
proper healing.
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4012 S Lynn Ct Drive   •   INDEPENDENCE, MISSOURI 64055   •   816-252-3545
Post-Operative Instructions for Scaling
and Root Planing (Deep Cleaning)
If you or a family member has recently had a deep cleaning at
our office, please follow these instructions to ensure proper
healing.
Post-Operative Instructions for Dental
Crowns
If you or a family member has recently received a dental crown
at our office, please follow these instructions to ensure proper
healing.
Post-Operative Instructions for Root
Canals
If you or a family member has recently received a root canal at
our office, please follow these instructions to ensure proper
healing.