Patient Forms
Copper Canyon Family Dentistry Patient Forms
In the areas and links below you can access all of the forms that we may require you to fill out and submit to us. These forms are in pdf format and must be printed, filled out, then given to us when you visit us.

Patient Registration Form
Click Here for Patient Registration Form (pdf)

Medical History Form
Click Here for Medical History Form (pdf)

Dental Insurance Coverage Form
Click Here for Dental Insurance Coverage Form (pdf)

Financial Responsibility Contract
Click Here for Financial Responsibility Contract (pdf)

New Patient Acknowledgement of Privacy of Practices
Click Here for New Patient Acknowledgement of Privacy Practices (pdf)

Patient Notice of Privacy of Practices
Click Here for Notice of Privacy Practices (pdf)

Authorization for Disclosure of Information
Click Here for Authorization for use or Disclosure of Information Form (pdf)