919-469-9986 DIPLOMATES OF THE AMERICAN BOARD OF PERIODONTOLOGY

Patient Information

Attention New Patients:

Please complete the following forms: Health History, HIPAA Notice, Acknowledgment Form, Authorization for Information Release, Financial/Scheduling Policy, and Dental Insurance Information (if applicable). 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 info@caryperio.com. (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.

Health History

Registration & Health History Form (PDF)

 

Privacy Practices

Notice of Privacy Practices (PDF)

Acknowledgement Form (PDF)

Authorization for Release of Information to Family and/or Friends (PDF)

Scheduling and Financial Policies

Scheduling and Financial Policies (PDF)

Dental Insurance

Dental Insurance Information Form (PDF)


Links About Dentistry and Periodontology

American Academy of Periodontology

American Board of Periodontology

American Dental Association