Patient Forms

We look forward to welcoming you as a new patient to our dental family!

When you schedule your new patient appointment, we will text you a link to the new patient paperwork. Please fill these out prior to your first appointment.

HIPAA Notice of Privacy Practices Acknowledgement

Download a version of our HIPAA Notice of Privacy Practices where you can sign acknowledging that you have received it.
(Note that you must open the downloaded document in Adobe Acrobat to be able to sign it electronically. Signatures do not work when the document is opened within a web browser.)

Website Version: HIPAA Notice of Privacy Policies

TEXT OUR OFFICE

Text message is limited to 1000 characters.

I consent to allow The Yuma Dentist to send text messages to my wireless phone number. Message frequency may vary. I understand I may opt-out at any time by replying "Stop".

HOW IT WORKS

  1. Enter your Name.
  2. Enter your Cell Phone Number, area code first.
  3. Enter your text message in the box.
  4. Select which office you want to text.
  5. Click "Send Text".
  6. A copy of this text will be sent to the office and to your cell phone. The office's reply will also be sent to your cell phone where you can continue the text conversation.
Note: Mobile message and data rates from your cell phone carrier may apply.Close ClickToCall Button
NagiosCheckValue - Do not remove please