Longmeadow Family Dental Care Longmeadow Family Dental Care

Patient Forms

There are a number of patient forms the law requires you read and fill out before we can begin treating you. All of these patient forms are provided below so you can fill them out beforehand and bring them with you on your first visit.

Privacy Acknowledgement (pdf)

Signing this document verifies that you’ve received a copy of our privacy practices and are aware of them. Our privacy practices notice can be found below.

Financial Responsibility (pdf)

We’re committed to providing you with the best possible care. Your clear understanding of our financial policy is important to our professional relationship.

Records Release (pdf)

Filling out this form allows us to disclose your dental/medical records to anyone of your choosing (typically family members).

Records Request Form (pdf)

Appointment Cancellation & No Show Policy (pdf)

We understand there are times when you must cancel an appointment due to emergencies or obligations for work or family. However, time has been specifically reserved for your appointment. Please call at least 24 hours prior to your appointment if you must cancel. We try very hard to keep our schedule, and hope our patients do as well.

Patient Information (pdf)

New patient? We need some information from you before your first visit.

HIPAA Privacy Form (pdf)

We’re required to give you this HIPAA notice about our privacy practices.

HIPAA Acknowledgement Form (pdf)