Dental Patient Forms
Whether you are a New Patient or a Current Patient, your basic information is very important. We are required annually to obtain updated information from our patients. Please bring with you your Photo ID, Insurance Card (if any), Medical History and Prescription information (preferably current Rx bottles). To speed up the Check-In process, these forms may be printed, completed prior to your appointment and brought with you. If you have any questions about the forms, please call one of our offices at (208) 356-4900.
Dental Patient Registration Packet
Our Patient Registration packet requires basic information that we are required to collect. Please complete the entire form, sign and date. The forms can be downloaded and completed on your computer. You will then have the option to submit electronically or print out, sign, and bring with you to your appointment.
New Adult Patient Registration Packet:
For those who need to do an annual update:
To apply for our Sliding Scale discount, which is based on your household size and income, please complete the Sliding Scale Application. The information on this application also has to be verifiable and proof of income must be submitted to our facility within 3 days of your appointment, otherwise full fees will be charged.
Proof of income options
Patients who wish to apply for sliding fee discounts are only required to provide one of the following:
- 2 most recent pay-stubs for all members of the household who are working
- Previous year’s tax documents
- Social Security or Disability income statements
- If you have no verifiable income, a letter from someone close to you (may not be a family member) that can verify your income and financial situation. This letter must be signed and dated, and a phone number to reach this person is required.
- If you have recently started a new job, the employer may either write a letter or you may have them complete our Income Verification form. This form must be signed and dated.
HIPAA Notice and Form
Your Privacy is very important to us! If you ever have a concern or question, please contact our facility ASAP. The HIPAA/Privacy Notice is a document for your information.