Patient Forms

If you would prefer, you can print out, complete and sign our patient forms to speed up checking-in for your first visit so we can get you in to see Dr. Buchwald as soon as possible.  If available, please remember to bring in your insurance card when you come in, so we may make a copy of it for our records.

	Description	Last Updated	Download
Children's Welcome Form	Please fill this out and turn it in at the front desk for your child when you arrive for your appointment.	3/1/2009	Here
Adult's Registration Form	Please fill this out and turn it in at the front desk when you arrive for your appointment.	3/1/2009	Here
HIPAA Notice of Privacy Practices	Please fill this out and turn it in at the front desk when you arrive for your appointment.	3/1/2009	Here
Nota de HIPAA de Practicas de Intimidad	Por favor, rellene esto y convertirlo en en la parte delantera escritorio cuando usted llegue a su cita.	3/1/2009	Aqui
Financial Policy Form	To keep our fees as low as possible, payment is expected on the date services are initiated. In some instances, we may ask that you prepay for your dental services to reserve special appointment times... This form needs your signature.	1/1/2008	Here
Credit Card Pre-Authorization Form	This optional pre-authorization policy was created in response to many of our patient's desire to not be billed for small balances on their accounts remaining after all insurance payments have been made. As a convenience to you, this form provides us with the authorization to charge your credit card for outstanding balances up to $99.00 if this occurs.	1/1/2010	Here
	Documents are in .pdf format. Adobe® Acrobat® Reader® is free software that lets you view and print Adobe Portable Document Format (PDF) files. Click here to download it for free.