Gainesville Dentist | Gainesville dental care | VA | Forms

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A Smile Can Change Everything

14535 John Marshall Hwy
Suite# 101
Gainesville, VA 20155
(571) 261-2330
     On Route 55 near the Haymarket Post Office
 on the same side of the road.
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HIPPA Notice of Privacy Practices

(23KB)

Use of protected health information

Describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law.


New Patient Form

(30KB)

For first-time patients

Required to be filled out by all new patients coming to the practice for the first time. Please fill this form and bring along with you during your first visit.


Medical History Form

(196KB)

Patient's Medical History

Required to be filled out by all new patients coming to the practice for the first time. Please fill this form and bring along with you during your first visit.


Guardian Authorization Form

(52KB)

For children's treatment

Authorization given by an adult to agree for the treatment of a child. Please fill out this form and bring with you when bringing in a child for treatment.


HIPPA Consent Form

(13KB)

Use of protected health information

This form allows us to file your insurance on your behalf with your consent to disclose this information to the insurance company and any involved third party.

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DISCLAIMER OF Gainesville Family Dentistry

Gainesville Family Dentistry expressly disclaims all warranties and responsibilities of any kind, whether express or implied, for the accuracy or reliability of the content of any information contained in this Web Site, and for the suitability, results, effectiveness or fitness for any particular purpose of the services, procedures, advice or treatments referred to herein, such content and suitability, etc., being the sole responsibility of parties other than Gainesville Family Dentistry and the reliance upon or use of same by you is at your own independent discretion and risk.


 

 
 
Gainesville Dentist | Forms. Dr. Rama Goswami is a Gainesville Dentist.