New Patients – Fill Out Forms Prior to Your First Visit


 

Forms

HIPAA Acknowledgement – This form is a standard form letting you know your privacy rights.
Patient Registration – This form is to be filled out prior to your visit.
Medical History – This form is your confidential medical history; Please fill out completely.

Please Fax to 281-304-9930

Our office adheres to the requirements outlined by the Health Insurance Portability and Accountability Act (HIPAA), which ensures security and privacy of an individual’s medical records and promotes privacy and trust between patients and their health care providers.

As part of HIPAA requirements, all new patients seeing their health care provider upon their initial visit are required to sign an acknowledgment form to indicate that they have received the Privacy Notice. The Privacy Notice describes how the hospital/provider uses and shares your personal health information.

Call or e-mail us for more information about your privacy rights as a patient.

What we offer

Services

Location
Charles E. Dyer, IV, DDS, MS, PC
13611 Skinner Road, Suite 230
Cypress, TX 77429
Phone: 281-223-1919
Fax: (281) 304-9930
Office Hours

Get in touch

281-223-1919