Forms

You have the option of printing out and completing the necessary forms in the comfort of your own home, or we ask that you come 20 minutes early to fill them out in our office. The choice is yours!

 


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1. Health History (2 pages)

PLEASE DO NOT DRAW STRAIGHT LINE THROUGH THE BOXES: CHECK EACH BOX INDIVIDUALLY!!! You will be asked to fill the form out again if the boxes are not checked individually. Thank you!


2. Office Procedures and Policies (2 pages)

This form explains general policies about our office.


3. HIPAA (3 pages: 2 to read, 1 to sign)

HIPAA stands for “Health Insurance Portability and Accountability Act.” This federal act created national standards to protect individuals’ medical records and other personal health information.

Please do the following:

  1. READ the “Notice of Privacy Practices.
  2. SIGN EITHER:
         “Consent for Use and Disclosure of Health Information
               OR
         “Consent for Use and Disclosure of Health Information -
    Minor, or Unable to Sign For Self.

    (You may put one or more children on the first line of the form)

**** You only need to return the Consent: You do not have to

       bring the Notice


(973) 209 - 6252 ~ 15 VERNON AVENUE, SUITE 101 ~ HAMBURG, NJ 07419        

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Hamburg Family and Cosmetic Dental Group, LLC ~ 15 Vernon Avenue, Suite 101 ~ Hamburg, NJ 07419
©2009 Jinu Kurian, DDS
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