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Patient Forms - Champaign Dentists | Hans Family Dental

FORMS

New Patients:

Please click the following links fill out required forms:

Patient Information (submit online)

Insurance Information (submit online)

Health and Medical History (submit online)

ADA Covid Patient Screening form (submit online)

HIPAA (print and keep for your records)

Authorization to Release Information (submit online)

 

Existing Patients:

Patient Information (submit online)

Insurance Information (submit online)

Update Health and Medical History (submit online)

ADA Covid Patient Screening form (submit online)

 

Would you rather just print the forms?

No problem! Print the forms you need below, fill them out, and bring them with you.

Update Health and Medical Form (print, complete, & bring with you)

Authorization to Release Information (print, complete, & bring with you)

HIPAA (print and keep for your records)

 

 

©2020 Copyright - Hans Family Dental - - All Rights Reserved. Dentist in Champaign IL 61820 offering dental exams, braces/Invisalign, root canals, cleanings, and more.

Please fill out and submit our Covid Patient Screening Form prior to arrival