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Mauldin Family Dentistry
Dr. Daniel J. Halasz
Creating Beautiful Smiles

Patient Forms

WELCOME TO MAULDIN FAMILY DENTISTRY!

We look forward to meeting you in person at your first appointment.  If you have not already made an appointment, and would like to, please submit a request or call our office today.

Before you come in, we thought you might appreciate some information about our practice and what to expect during your visit.  We may be a little different than dentists you've had in the past. We believe that achieving and maintaining healthy teeth and gums takes a team effort and that you play as big a role as we do in reaching that mutual goal. So, you can expect to be extensively involved in your treatment program.   

Below, you will find our New Patient Forms, which will provide our office with basic information about you.  This includes details on any Dental Insurance plan(s) you may have, as well as your medical history, which is vital in developing your treatment plan. Please fill them out 24 hours prior to your first appointment, which will allow us to attend to your dental needs more quickly.  Please also remember to bring your dental insurance card, as well as a current Picture I.D.

If you have dental insurance, we will file any charges incurred during your visit with them, and any uncovered charges will be balance-billed to the responsible party on your account.  If you do not have dental insurance, we ask that you pay for services in full on the day of your appointment in form of cash or check (we also accept VISA, MasterCard, Discover, AMEX and CareCredit). For more information on our Financial Policy, please reference our Financial Policy document below.

If you have any questions, please call us at any time. We welcome you to our practice and look forward to meeting you soon!

 

NEW PATIENT FORMS

COVID-19 Treatment Consent

Patient Information Form

Insurance Information Form

Patient Medical History Form

Dental Questionnaire

Mauldin Family Dentistry Financial Policy

Notice and Acknowledgement of Privacy Practices (HIPPA)

Records Release Form







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