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) or POS (Physician Order Sheets)
    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