We are now part of the Delta Dental PPO and Delta Dental Premier® programs as of January 1, 2020.
Attention New Patients:
Please complete the following forms: Registration Form, Dental & Medical History Form, HIPAA Acknowledgment Form, Authorization for Release of Information, and Scheduling & Financial Policy. Links to the forms are listed below.
Bring the completed forms to your appointment, or fax it to us at 919-469-2034, or email it to us at firstname.lastname@example.org. (Be sure to print the forms before trying to fax or email.)
If you are unable to complete your forms prior to your appointment, please plan to arrive 10 to 15 minutes early.
Registration and Insurance Form (PDF)
Dental & Medical History
Dental and Medical History Form (PDF)
HIPAA and Privacy Practices
HIPAA Notice of Privacy Practices (PDF)
HIPAA Acknowledgement Form (PDF)
Authorization for Release of Information to Family and/or Friends (PDF)
Scheduling and Financial Policies
Schedule and Financial Policy (PDF)
Care Credit Information
Proceed Finance Information
Links About Dentistry and Periodontology
American Academy of Periodontology
American Board of Periodontology
American Dental Association