Forms
For your convenience, please find a list of forms below. Please print them off and bring them to your appointment.

Insurance Card
HIPAA Acknowledgment Form
HIPAA Authorization Form
Medical History
Patient Information Form
Notice of Privacy Policy
Records Request from East Main Dental Center
Records Request to East Main Dental Center










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East Main Dental Center | www.eastmaindentalcenter.com | (541) 773-3422
1123 East Main Street, Medford, OR 97504



 

 

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