Patient Forms

Our team is ready to answer any questions you have about our dental procedures and pricing in order to make the most out of your appointment and stay vigilant about your tooth care.

Please fill out the forms below before your first appointment to speed up the check-in process. If you need help filling out any of these forms, or have questions about any of our policies and dental benefit plans, please get in touch with us by calling 610-562-7348.

At Hamburg Family Dental, we strive to make every experience here pleasant and informative.

Consent to Treat Minor

For patients who are coming under the age of 18 without a parent/guardian present. Please have parent/guardian complete prior to arrival.

New Patients

New Patients

Adults
Children under age 18

New Adult Patients - please fill out all forms in this category.

Health History

Health History Form for patients age 14 and over

HIPAA Consent

Please list anyone you would like to have access to your information

Insurance / Financial

Insurance & Financial Agreement

Record Release

This form will help us to obtain records from your previous office so we can better serve you.

Patient Privacy Notice

This form does not need to be printed, but feel free to read over prior to signing the acknowledgement.

469 W State St.
Hamburg, PA 19526
Phone: 610-562-7348
Fax: 610-562-3454
info@hamburgfamilydental.com

Monday  
7:30 AM - 4:00 PM
Tuesday  
7:30 AM - 4:00 PM
Wednesday  
7:30 AM - 3:30 PM
Thursday  
7:30 AM - 3:30 PM
Friday - Sunday  
Closed
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