As a service to make your visits to us as trouble-free as possible, we provide the following forms and information to you in Adobe Acrobat format. When necessary, please download and print these forms to your own computer, then fill them out at your convenience and bring them along with you. We've also provided information sheets to assist you in making medical and financial decisions.
Before You Visit Us —
Please note that all of these completed forms are necessary for your
first visit:
Financial Options Acknowledgement
Acknowledgement of Receipt of Notice of Privacy Practices
Learn More About Your Options —
Composite Restorations and your Insurance Coverage
Valachi Dental Mission Statement
- For your convenience, we have made this forms available for you to complete in the comfort of your own home or office. Please provide as complete information as possible, especially regarding your medical history and any prescription or over the counter medications you are currently taking. Please include accurate dental insurance information so that we may help you obtain the maximum from your dental benefit plan.
Download (155kb)
Acknowledgement of Financial Options
- We explain your various options for payment, and set forth our appointment policy. Please read and sign this form, and bring it along with you on your first visit. Download (130kb)
- Describes how health information about you may be used and disclosed and how you can get access to that information - 2 pages
Download (400kb)
Acknowledgement of Receipt of Notice of Privacy Practices
- A brief form for your signature stating that you've read the Privacy Practice (above). Download (70kb)
How We Facilitate Your Best Insurance Options
- Our patients with dental insurance often have questions about how their interests are best represented. This short overview explains our service to you. Download (135kb)
Composite Restorations and Your Insurance Coverage
- Are composite fillings or amalgam (silver) fillings best for you? What are the differences? What are your options for restoration regarding insurance coverage? Download (145kb)
Valachi Dental Mission Statement
- Our entire staff is dedicated to your comfort and dental health. We've set forth this dedication in our Mission Statement, which we share with you. Download (570kb)
