Welcome to Clearwater Dental

New Patient Forms

Submit your forms direclty online to save time at the office.






To save time from filling out paperwork in the office, you can fill out and submit the online form directly below, or you can print out the PDF forms on your own to fill out and bring into the office (or mail to: Clearwater Dental, 5000 W Clearwater Ave, Kennewick, WA 99336).

New Patient Questionaire (PDF)
Tell us a little about yourself so we can best serve you and your unique needs.
Medical History (PDF)
This provides us awareness of any diseases and medications that might impact with your dental treatment.
Acknowledgement of Notice of Privacy Practices (PDF)
​​We require acknowledgement of our Notice of Privacy Practices (PDF) so you know your privacy is protected.

Part 1: New Patient Questionnaire

Tell us a little about yourself so we can best serve you and your unique needs.


Basic Information


What did you like or dislike about your previous dentist?


Part 2: Your Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body.
Please share with us any health problems that you may have, or medication that you may be taking.

Women: Are you…

Are you allergic to any of the following?

Others


Do you have, or have you had, any of the following?

Comments


Part 3: Acknowledgement of Notice of Privacy Practice

We keep a record of the health care services we provide you. By my signature below, I acknowledge receipt of the Notice of Privacy Practices for Clearwater Dental. We will not disclose your record to others, unless you direct us to do so or unless the law authorizes or compels us to. Our Privacy Practices describes in more detail how your health information may be used or disclosed, and how you can access your information. You may ask to see and copy that record at any time.

Authorization to disclose Medical / Dental Information to a Family Member or Designated Person.

By my signature below, I give my written permission to allow the providers and staff of Clearwater Dental to share my dental / health information with:


Part 4: Electronic Signature

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.

I agree to be responsible for the payment of all services rendered on my behalf or my dependents. I am aware that all balances over 90 days will be accessed a finance charge.

In the case that I have dental insurance, I authorize and request my insurance company to pay directly to Clearwater Dental, otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. Therefore; I am responsible for any remaining balance.





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