Midtown Dental

The following forms can be downloaded and printed before your visit to save you
time and keep you from having to arrive early for your appointment. Please
download all five of the forms and fill them in completely. If you have questions or
are unsure about something, please call us at 501-664-5555 and we'll be happy
to help you out. To view these forms, you'll need the free Adobe Reader program.


This Financial Contract is a legal agreement between you and Midtown Dental. Please read it carefully before signing it. If you have any questions, contact us or ask someone you trust to explain it to you. While we will make every effort to work with Medicaid and any other insurance you may have, you as the patient are ulitimately responsible for payment. Financial Contract This Notice of Privacy Practices explains how we will keep your private health information confidential. It explains who we may share your information with, and why. If you have any questions, please contact us, or ask someone you trust to explain it to you. Notice of Privacy Practices This Privacy Acknowledgement form signifies that you have read the Notice of Privacy Practices form listed above, and have accepted its terms. Notice of Privacy Practices Acknowledgement		The registration forms below provide us with your basic health information, including your medical history, medications you are taking, and known allergies. It is very important that you fill these two forms out carefully. Registration Form 1 Registration Form 2
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This Financial Contract is a legal agreement between you and Midtown Dental. Please read it carefully before signing it. If you have any questions, contact us or ask someone you trust to explain it to you. While we will make every effort to work with Medicaid and any other insurance you may have, you as the patient are ulitimately responsible for payment.

Financial Contract

This Notice of Privacy Practices explains how we will keep your private health information confidential. It explains who we may share your information with, and why. If you have any questions, please contact us, or ask someone you trust to explain it to you.

Notice of Privacy Practices

This Privacy Acknowledgement form signifies that you have read the Notice of Privacy Practices form listed above, and have accepted its terms.

Notice of Privacy Practices Acknowledgement

The registration forms below provide us with your basic health information, including your medical history, medications you are taking, and known allergies. It is very important that you fill these two forms out carefully.

Registration Form 1

Registration Form 2

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