Hipaa Forms

New to the Mint Hill Area?

What can I expect on my first visit?

Upon arriving, you will be asked to complete a general and dental health history form. This form is also available online if you would like to complete it ahead of time.

Your dental and oral health will be assessed with a comprehensive oral evaluation. We will also take digital photos and X-rays of your teeth to identify any areas of concern. Our goal will always be to preserve as much of your teeth as possible by catching any decay in its earliest stages.

What do I need to bring with me or prepare ahead of time for my visit?

  • A list of any current medications and alert the staff to any allergies
  • Any completed medical forms
  • Insurance provider verification card

Consider mentioning these topics during your appointment:

  • Any current concerns and/or pain with your teeth
  • Your goals regarding your smile, teeth and gums
  • Future plans for treatment

What do I need to prepare if I am bringing my child for the first time?

Any child under the age of 18 will need to be accompanied by a parent or guardian. You will need to complete the patient registration for your child, which can be done ahead of time or completed when you arrive to the office.

It is a group effort with our staff and the parent/guardian to make the child’s experience at our dental office as enjoyable as possible.

Payment options:

East Charlotte Dental is dedicated to helping you obtain the healthy, beautiful smile you want and deserve. We currently offer these payment options:

  • Most major insurances, including Blue Cross Blue Shield, Cigna, Aetna, Delta, NC Health Choice and Medicaid
  • Cash
  • In House Patient Dental Plans (Friendly Dental Plan)

HIPAA Forms

Release of Medical Records
Accounting of Disclosures
Record Release to Patient
Alternative Communications
Web & Social Media Release Form
Notice of Privacy Practices – English
Aviso de Prácticas de Privacidad – Español

Privacy Practice Consent Release Form – English
Formulario de Autorización de Consentimiento de Práctica de Privacidad – Español

 

24/7 Online Scheduling