{"id":19,"date":"2021-04-12T12:54:54","date_gmt":"2021-04-12T20:54:54","guid":{"rendered":"https:\/\/statefamily.wpengine.com\/?page_id=19"},"modified":"2023-08-03T10:39:59","modified_gmt":"2023-08-03T18:39:59","slug":"patient-forms","status":"publish","type":"page","link":"https:\/\/49thstatedental.com\/patient-forms\/","title":{"rendered":"Patient Forms"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.9.4&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#0e1d61&#8243; custom_padding=&#8221;0px||0px||false|false&#8221; global_module=&#8221;107&#8243; saved_tabs=&#8221;all&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; custom_margin=&#8221;0px||0px||false|false&#8221; custom_padding=&#8221;0px||0px||false|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text disabled_on=&#8221;on|off|off&#8221; admin_label=&#8221;DESKTOP &#038; TABLET:  Telephone \/ Office Hours &#8221; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; text_font_size=&#8221;19px&#8221; text_orientation=&#8221;center&#8221; background_layout=&#8221;dark&#8221; custom_padding=&#8221;3%||||false|false&#8221; text_font_size_tablet=&#8221;15px&#8221; text_font_size_phone=&#8221;12px&#8221; text_font_size_last_edited=&#8221;on|tablet&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p><strong>Call for an appointment:<\/strong> <a style=\"color: #fff;\" href=\"tel:9075615154\">(907) 561-5154<\/a> | <strong>Hours:\u00a0<\/strong> Monday &#8211; Friday, 8:30am &#8211; 5:00pm<\/p>\n<p>[\/et_pb_text][et_pb_text disabled_on=&#8221;off|on|on&#8221; admin_label=&#8221;MOBILE &#8211; Telephone \/ Office Hours&#8221; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; text_font_size=&#8221;19px&#8221; text_orientation=&#8221;center&#8221; background_layout=&#8221;dark&#8221; custom_margin=&#8221;2%||2%||false|false&#8221; custom_padding=&#8221;2%||||false|false&#8221; text_font_size_tablet=&#8221;15px&#8221; text_font_size_phone=&#8221;12px&#8221; text_font_size_last_edited=&#8221;on|tablet&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p style=\"text-align: center;\"><strong>Call for an appointment:<\/strong> <a style=\"color: #fff;\" href=\"tel:9075615154\">(907) 561-5154<\/a><br \/><strong>Hours:\u00a0<\/strong> Monday &#8211; Friday, 8:30am &#8211; 5:00pm<\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; admin_label=&#8221;section&#8221; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_row column_structure=&#8221;1_2,1_2&#8243; admin_label=&#8221;row&#8221; _builder_version=&#8221;4.16&#8243; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;1_2&#8243; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;|||&#8221; global_colors_info=&#8221;{}&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_text admin_label=&#8221;Patient Forms&#8221; _builder_version=&#8221;4.21.0&#8243; _module_preset=&#8221;default&#8221; hover_enabled=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221; sticky_enabled=&#8221;0&#8243;]<\/p>\n<h2>Patient Forms<\/h2>\n<ul>\n<li><a href=\"https:\/\/49thstatedental.com\/wp-content\/uploads\/2021\/04\/Health-History.pdf\" target=\"_blank\" rel=\"noopener\">Patient Health History (PDF) \u00bb<\/a><\/li>\n<li><a href=\"https:\/\/49thstatedental.com\/wp-content\/uploads\/2023\/02\/Records-Release-Form.pdf\" target=\"_blank\" rel=\"noopener\">Patient Release of Records (PDF) \u00bb<\/a><\/li>\n<li><a href=\"https:\/\/49thstatedental.com\/wp-content\/uploads\/2023\/08\/Financial-Policy-August2023.pdf\" target=\"_blank\" rel=\"noopener\">Financial Agreement (PDF) \u00bb<\/a><\/li>\n<li><a href=\"https:\/\/49thstatedental.com\/wp-content\/uploads\/2021\/07\/Hippa2-1.pdf\" target=\"_blank\" rel=\"noopener\">Privacy Statement (PDF) \u00bb<\/a><\/li>\n<li><a href=\"https:\/\/49thstatedental.com\/wp-content\/uploads\/2021\/07\/HIPPA-document-09242017-v2.pdf\" target=\"_blank\" rel=\"noopener\">HIPPA (PDF) \u00bb<\/a><\/li>\n<\/ul>\n<p>We offer translation services for non-English speakers.<\/p>\n<p>[\/et_pb_text][\/et_pb_column][et_pb_column type=&#8221;1_2&#8243; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;|||&#8221; global_colors_info=&#8221;{}&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_image src=&#8221;https:\/\/49thstatedental.com\/wp-content\/uploads\/2021\/06\/49th-State-Dental-20210625-0840.jpg&#8221; title_text=&#8221;49th State Dental-20210625-0840&#8243; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][\/et_pb_image][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Call for an appointment: (907) 561-5154 | Hours:\u00a0 Monday &#8211; Friday, 8:30am &#8211; 5:00pmCall for an appointment: (907) 561-5154Hours:\u00a0 Monday &#8211; Friday, 8:30am &#8211; 5:00pmPatient Forms Patient Health History (PDF) \u00bb Patient Release of Records (PDF) \u00bb Financial Agreement (PDF) \u00bb Privacy Statement (PDF) \u00bb HIPPA (PDF) \u00bb We offer translation services for non-English speakers.<\/p>\n","protected":false},"author":5,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","footnotes":""},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v22.4 - 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