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Patient Forms

To expedited the new patient registration process we have attached all of the forms that need to be filled out and either faxed to us at 703-560-1745, or mailed to our attention at 8505 Arlington Blvd., Ste 260, Fairfax, VA 22031 or brought in with you at the time of your appointment.

The first form is the "New Patient Health History". This needs to be filed out completely for your first appointment and thereafter every three years.

The second form is the "Smile Assessment". This form helps us determine your dental needs and wants.

The last two forms are your "HIPPA Privacy Act" and receipt of "Acknowledgement of your Privacy Act". The HIPAA Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of personal health information needed for patient care and other important purposes. For more information you can check out the following website - http://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html

Thank you for your cooperation.

Download and print patient forms:

• New Patient Health History Registration
• Smile Assessment
• HIPAA Privacy Act, page 1,  page 2
• Acknowledgement of Receipt of Privacy Act

Online patient registration:

• Click to access our online registration form for new patients.

 

DENTAL SAVINGS PLAN ENROLLMENT FORM
Please print out and submit with Check, Cash or Credit Card. Make checks payable to: H.Charles Jelinek, Jr., D.D.S.
Enrollment Form

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