Joe W. Potter

Forms

The following forms are available to be downloaded, filled out and returned to our office. Each form is in PDF format. You will need Adobe Acrobat (Reader Only) to access the forms.

Patient Understanding and Informed Consent
Consent for Use and Disclosure of Health Information
Acknowledgement of Receipt of Notice of Privacy Practices
Consent for Insurance Release
Radiographs and Records Release Request
Financial Responsibility / Waiver Form
Patient Information / Dental and Medical History Form


Patient Understanding and Informed Consent	Consent for Disclosure of Health Care Information

Acknowledgement of Receipt of Notice of Privacy Practices	Consent for Insurance Release

Radiographs and Records Release Request	Financial Responsibility / Waiver Form

Patient Information / Dental and Medical History Form

If you are not able to download the forms above, you may need to download and install a free copy of the Adobe Reader by clicking here. Caution: watch for additional software offers (toolbars, etc) during the download process. You only need the reader to open the online forms on this page.