About Our Forms

For your convenience, we have provided forms for you to fill out in advance of your appointment. We ask that you complete the New Patient Form, Privacy Practice Statement, Privacy Practice Acknowledgment and Office & Financial Policy. We have provided explanations for each form, below:
Health History and Financial Agreement Form

We ask that you complete the health history form to give Dr. Atherton an accurate picture of your child’s health history, current health issues and any current medications. Your signature at the bottom of the health history will confirm your informed consent for Dr. Atherton to perform the necessary dental services your child may need. There is also financial agreement in the Health History form which designates that you are the responsible party and will be billed for payment accordingly. If special arrangements are necessary, please call the office.

HIPAA – Health Insurance Portability and Accountability Act Form

Dental practices must be in compliance with federal laws that help protect patients from misuse of personal information.

By signing this form you are acknowledging that Dr. Atherton’s office has provided you with information about rights regarding your child’s information. The additional disclosure authority grants relatives access to your child’s health records and allows them to discuss health issues with Dr. Atherton. A care provider may still seek emergency help from Dr. Atherton even if they are not listed on the disclosure form.

If you have any question regarding completion of the patient forms, please call the office.