Please download, print and complete the following forms and bring them with you to your first appointment. These forms are in .pdf format and require Adobe Acrobat reader, available as a free download at www.adobe.com
Click the document name to open and print the document
Call us at 505-891-1500 if you have any questions
Office Policy & Statement of Financial Responsibility
A description of hours and appointment policies, minor patient policy (patients under the age of 18), our returned check policy and patient information.
We will work with you to ensure that insurance is filed for your first visit. If you have no insurance, payment in full is due at the time of service. Pearly Whites accepts Medicaid and Medicare and will bill services directly.
New Patient Information Sheet
Please complete the first two sections of the New Patient Information sheet.
Dental Registration and History
Complete the entire form as accurately as possible, providing personal, insurance and dental and health history information.
Notice of Privacy Practices page 1 page 2
Federal law requires that all patients receive information as to how their medical information may be used and disclosed. Please print and read this form carefully.
Privacy Practices Acknowledgement
Print and sign and date this form to acknowledge that you have read the Notice of Privacy Practices information .
