Patient Forms

 

At Hamburg Family Dental, we strive to make every experience here pleasant and informative. Our team is ready to answer any questions you have about our dental procedures and pricing in order to make the most out of your appointment and stay vigilant about your tooth care.

 

You can read up on our privacy and medical policies below, and we’ve also uploaded forms for you to fill out prior to your appointment in order to speed up the check-in process. If you need help filling out any of these forms, or have questions about any of our policies and medical plans, please get in touch with us by calling 610-562-7348.

 

 

Record Release - 

For patients transferring to our office, please fill out this form so we can obtain your records from your previous office 

Record Release - 

For patients transferring from our office, please for this form out and include your new office location so we can get your records sent to the correct location. 

New Patient- Adult (please fill out all forms in this category)

 

Adult Health History - 

For patients age 14 and older 

 

Insurance & Financial Agreement

 

Hipaa Consent- Please list anyone you would like to have access to your information

 

Record Release- This form will help us to obtain records from your previous office so we can better serve you.

 

New Patient- Children (under age 18, please fill out all forms in this category)

 

Children's Health History - 

For patients under 14

 

Hipaa Consent- Please list any family members that are allowed to have access to your child's information

 

Insurance & Financial Agreement

 

Record Release- This form will help us to obtain records from your previous office so we can better serve you

Children's Sleep Screening - 

For patients under 18

Patient Privacy Notice
This form does not need to be printed, but feel free to read over prior to signing the acknowledgement.
Patient Privacy Notice.pdf
Adobe Acrobat document [100.5 KB]

Make an Appointment Today!

Hamburg Family Dental

469 W State St.

Hamburg, PA 19526

Phone No. 610-562-7348

Fax No. 610-562-3454

 

Business Hours:

Monday          7:30 am - 5 pm

Tuesday         7:30 am - 5 pm

Wednesday    7:30 am - 3:30 pm 

Thursday        7:30 am - 3:30 pm

**Our office will be closed from Dec. 25, 2023 up until Jan. 1, 2024. We will back in the office with normal business hours starting Jan. 2, 2024.

 

Get Social With Us

Print | Sitemap
© Hamburg Family Dental