Patient Forms
In order to make your visit more efficient, we've made the following New Patient Forms available online. These forms comprise the information we'll need to know about you and your medical history. In addition, you'll learn some important details about Sepehri Dental, and our pledge to provide you with excellent care and handle your personal information with the highest discretion. We hope the ability to complete these forms at home offers you a convenient alternative to doing so during your appointment.
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Patient Information
Requests some basic information about the you and your insurance provider.
Dental and Health History
Provides us with information about your health, medications taken and previous care received.
Financial Policy
Details our policies regarding payment for services.
Esthetic Questionnaire
Inquires about your thoughts regarding the appearance and function of your teeth.
Notice of Privacy Practices
Describes how health information about you may be used and disclosed.
Acknowledgement of Receipt of Notice of Privacy Practices
Notifies us that you've read and understand the Notice of Privacy Practices.
Consent for Use and Disclosure of Health Information
Authorizes Sepehri Dental to disclose your health information for the purposes of treatment or payment activities.