20528 Boland Farm Rd., Ste. 215
Germantown, MD 20876
(301) 875-7477

Forms

PLEASE READ/PRINT THE WELCOME LETTER. IT WILL PROVIDE YOU WITH AN OVERVIEW OF THE PROGRAM AND WHAT WE'LL NEED FROM YOU TO BEGIN THE PROCESS OF BEING SEEN AS A NEW PATIENT FOR SENIOR SMILE.

 

PLEASE FAX ALL NECESSARY INFORMATION TO 301-637-3222

When all required information is received by the office, you'll receive a call to setup your first new patient visit.

 

FACILITY PATIENT FORMS

  1. From the Patient or Power of Attorney/Guardian:
    1. SENIOR SMILE CONSENT FORM (PART 1)
    2. SENIOR SMILE CONSENT FORM (PART 2) WITH FEES – will be mailed or emailed once PART 1 has been received by us
    3. CREDIT CARD AUTHORIZATION FORM
    4. FINANCIAL TERMS AND CONDITIONS
    5. CONSENT FOR TESTING
    6. PHOTO CONSENT
    7. ORAL SURGERY CONSENT (if needed)
  2. From the FACILITY:
    1. FACE SHEET (Has patient’s Full Name, DOB, Soc Sec Number, Responsible Party information, etc)
    2. MARS (Medications Administration Reports), POS (Physician Order Sheets) or also known as their MEDICAL HISTORY NOTES

PLEASE CALL THE OFFICE IF YOU WANT TO DISCUSS THE FEES OF EACH PROCEDURE. THANK YOU.


HOMEBOUND PATIENT FORMS

  1. From the Patient or Power of Attorney/Guardian::
    1. MEDICAL HISTORY (HOMEBOUND)
    2. SENIOR SMILE CONSENT FORM (PART 1)
    3. SENIOR SMILE CONSENT FORM (PART 2) WITH FEES – will be mailed or emailed once PART 1 has been received by us
    4. CREDIT CARD AUTHORIZATION FORM
    5. FINANCIAL TERMS AND CONDITIONS
    6. CONSENT FOR TESTING
    7. PHOTO CONSENT
    8. ORAL SURGERY CONSENT (if needed)

PLEASE CALL THE OFFICE IF YOU WANT TO DISCUSS THE FEES OF EACH PROCEDURE. THANK YOU.