Patient Information Form
The patient information form is a required document that we recommend completing before your visit.
The information it provides regarding your current health, medical and dental history assists us in delivering the highest level of service and care.
We appreciate the confidence you place with us to provide dental services. If there have been any changes in your health, please tell us.
If you have any questions or would like additional information, we can be reached at any time via email or phone.
Statement of Privacy Practices
At Minnehaha Family Dentistry, we are dedicated to protect the privacy rights and confidential information of our patients.
We are committed to ensuring that your health information is never compromised by any of our employees. This is a principal concept of our practice.
We may, from time to time, amend our privacy policies and practices but will always inform you of any changes that might affect your rights.
Discrimination is against the law.
Minnehaha Family Dentistry complies with applicable Federal civil right laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. We provide free aid and service to people with disabilities to communicate effectively with us – including:
• Qualified sign language interpreters
• Written information in other formats (large print, audio, accessible electronic formats)
• Free languages services for non-native english speakers including written information
If you believe that Minnehaha Family Dentistry has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
or by mail or phone at:
U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.