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Patient Forms

Health History

All new patients requesting dental services are required to fill out patient registration forms and submit them before your first dental appointment. For your convenience, all patient forms are available on our website.
You can print this form, fill it out and fax it to 941-743-2988, mail it to our office, or bring it with you for your scheduled appointment.

Medical Records Release

A Medical Records Release Authorization is required for Port Charlotte, FL Periodontist Carol W. Stevens, D.D.S., M.B.A., to retrieve your medical records from another doctor or medical facility. You can print this form, fill it out and mail it to our office, fax it to 941-743-2988, or bring it with you for your scheduled appointment. By submitting this form you are authorizing Periodontist Carol W. Stevens, D.D.S., M.B.A. to retrieve your medical records.

Privacy Acknowledgement

You May Refuse To Sign This Acknowledgment.

This form acknowledges you have received our Notice of Privacy Practices. You can print this form, fill it out and fax it to 941-743-2988, mail it to our office, or bring it with you for your scheduled appointment. By submitting this form to Port Charlotte, FL Periodontist Carol W. Stevens, D.D.S., M.B.A. you are Acknowledging you have received a copy of this office’s Notice of Privacy Practices.