Dynasty Dental | New Patient Forms in Allen

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Dynasty Dental

(214) 547-8628


New Patient Forms

 

We know you have a busy schedule. To save time at your first appointment, you can download both the forms below. Please fill out New Patient Forms and Other Required New Patient Forms below out before your visit and bring them with you!

 

1. New Patient Form (Adults) /  New Patient Form (under 18 year old)

2. Other Required New Patient Forms

Includes:

  • Notice of Privacy Practices (Your Copy)
  • Assignment of Benefits and Payment Agreement
  • Consent for Use and Disclosure of Health Information
  • Acknowledgement of Receipt of Notice of Privacy Practices
  • Dental Treatment Consent Form 

 

Call (214) 547-8628 for an appointment now!

Be sure to bring along your insurance and identification card and you're all set! 


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Please do not submit any Protected Health Information (PHI).