Forms For Your First Visit
Thank you for choosing Pike Place Dental in Seattle Washington. For your convenience, this section includes forms you’ll need during your first visit, as well as what to expect when you come for your appointment. If you still have any questions about your visit, feel free to call your Pike Place Dental office. We’re here to help. Expand the menus below to see more.
Please complete the following information. Be sure to bring these to your first appointment.
- Adult Patient Health History Form
- Child Patient Health History Form
- HIPPA Privacy Practice Statement
- HIPAA Acknowledgement and Authorization for PHI Disclosure: We will provide a copy of our privacy policy practices at your appointment, or you may review them above. This form acknowledges that you have received them. It also provides instructions to Pike Place Dental about whom we may disclose information about your treatment.
- Patient Treatment and Financial Policy
Please take a moment to read these important notices prior to your appointment.
- Patients with certain medical conditions may need to take medication before seeing the dentist.
- About our Privacy Practices. We are required by law to provide you with information about our procedures to safeguard your personal health information.
Please arrive 15 minutes before your scheduled appointment. This will allow us to finish any paperwork and stay on schedule with your appointment. Please bring the following items with you to your first appointment:
- Patient Information Form (If you received from us in the mail)
- Dental Insurance Card Identification such as Driver’s license, military ID or state ID
- Patient Health History Form
- HIPAA Consent Form
- Patient Treatment and Financial Policy
