Patient Forms

New Patient Form

Please take a few minutes to answer the following questions so we can better assist you with your dental needs. Please list N/A for any fields that do not apply.


In case of emergency, who should we contact:

Primary Insurance

Additional Insurance

Dental History

Medical History

Assignment and Release

I hereby authorize payment directly to Mindy Fugett, DMD for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents.

I authorize the above doctor and/or any provider or supplier of services in this office to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

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HIPAA Privacy

I understand that according to the Federal HIPAA law that this office is unable to discuss my treatment, account balance or any other matters pertaining to me unless I indicate that they may do so. I agree that the following people can be informed of any association that I may have with this office including, but not limited to treatment, diagnosis, financial agreements, account balances and my general well-being.

Please List:

This consent applies until I ask that the name be deleted and a new form replaces this one. I certify that I have received a copy of the Join Notice of Privacy provided by Dr. Mindy’s Family Dentistry.

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Records Release

My signature below gives consent to do so.

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Important Insurance Message

Today, most insurance companies require that the patient be aware of the particulars of his/her insurance coverage. Further, the patient must fulfill certain requirements prior to being seen by a dentist. Your failure to comply may result in reduced payment or denial of your entire claim.


  • I have been advised that if services rendered by Dr. Mindy's Family Dentistry are considered to be "non-covered services" by my insurance company, I will be financially responsible.
  • I have been advised that if Dr. Mindy's Family Dentistry is not a contracted provider for my insurance company, I will be financially responsible for any and all charges rendered to me.
  • I have been advised that if I do not provide complete insurance information prior to my visit, Dr. Mindy's Family Dentistry cannot file a claim until all information is given and gathered. If I elect to receive care under these circumstances, I understand that I will be financially responsible for any and all charges for services rendered until coverage for such services can be verified.
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Please contact us if you have any questions or need any assistance with filling out our Patient Forms.