23219 Stringtown Rd, Box #324
Clarksburg, MD 20871
(301) 875-7477

Senior Smile

 

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
  2. From the Facility:
    1. Face Sheet
    2. MARS (Medications Administration Records)
    3. Financial Terms
    4. Consent for Testing

 

HOMEBOUND PATIENTS FORMS

  1. From the Patient or Power of Attorney (Guardian):
    1. SENIOR SMILE Consent Forms
    2. Medical History Form
    3. Financial Terms
    4. Consent for Testing