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Patient Forms

 

The first visit to our office is designed to get you better acquainted with all we offer as well as introduce you to our Doctor and our caring staff. We encourage questions and do our best to always deliver quality care.

Please take a moment prior to your scheduled appointment to download our patient forms. We ask that you complete the forms and bring them with you to your appointment along with a current medication list, so we may better assist you in a timely manner. 

Thank you for your confidence in our office, we look forward to assisting you with all your dental needs.

Marketplace Smiles Health History Form.pdf

Acknowledgement of receipt of notice of privacy practices.pdf 

Acknowledgement of Receipt, Consent, Use, Disclosure of PHI.pdf 

Please fill this form out if you have dental insurance that you would like us to file to for you. Please bear in mind that Dr. Bell is a Out of Network Provider. He is not contracted with any dental insurance companies, but our office can file to the out of network portion of insurance on behalf of our patients. 

Dental Insurance Verification Form.pdf

Patient Consent to Release Health information

Please fill out this form if you are leaving our practice and would like our office to release your records to another entity. To expedite the release please provide an email address to the new entity that they prefer records to be sent to.

Pt Authorization to Release Records. pdf


This web site uses files in Adobe Acrobat Portable Document Format (pdf) which require Adobe® Acrobat® Reader for viewing and printing. It is available to download free.

 

Contact Us.We encourage you to contact us with any questions or comments you may have. Please call our office or use the quick contact form.

Contact Us

We encourage you to contact us with any questions or comments you may have. Please call our office or use the quick contact form below.
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