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

Patient Information

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 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.

Registration

Registration 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

Scheduling and Financial Policy (PDF)

 


Links About Dentistry and Periodontology

American Academy of Periodontology

American Board of Periodontology

American Dental Association