paul e. coggins


GENERAL DENTISTRY    Call us at 919-832-0168    Map and Directions
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Patient Forms

Patient Registration 2017

Patient Registration Form

Medical History Form

Dental Records Release Form

HIPAA Notice of Privacy Practices Form

HIPAA Acknowledgement Form

Signature on File (for Insurance only)

Financial Policy

Instructions: You will need Adobe Reader to view these forms. You may choose to download them, fill them out on your computer, and then save them on your computer. Please print them out and bring them with you to your first appointment. You may also choose to attach the completed PDF files to an email message addressed to This email address is being protected from spambots. You need JavaScript enabled to view it.. We will have them printed and ready for you to sign when you come to your first appointment.

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