Patient Forms

Prepare For Your Dental Care Visit Here Ahead Of Time

<strong>Prepare For Your Dental Care Visit Here Ahead Of Time</strong>

By clicking the links below, you can view and print our forms in PDF format. Once they’ve been printed, you will need to fill them out and bring them with you to your first dental appointment with us. All patients will need to download and fill out a Health History form and Patient Registration form. Please bring these completed forms with you to your scheduled appointment. Set yours up by calling us today for dental care in Holly Springs, NC.

Call us now to set up your appointment: 919.290.2772 

Adult Patient Health History

Thumbnail 220x PDF
You are more than welcome to print and fill out both of these forms before coming in for your scheduled appointment. This form is for adult patients, 14 years of age and older.
To make things easier for you, we welcome you to click on each PDF file to download, print, fill out and take with you to your next appointment.

Download "HS-adult-form.pdf"

Child Patient Health History (Infant to 13 years)

Thumbnail 220x PDF
You are more than welcome to print and fill out both of these forms before coming in for your scheduled appointment. This form is for children, ages infant through 13 years of age.
To make things easier for you, we welcome you to click on each PDF file to download, print, fill out and take with you to your next appointment.

Download "HS-child-form.pdf"

New Patient Registration

Thumbnail 220x PDF
If you are a new patient to Holly Springs Family Dentistry, then welcome to our practice! You are more than welcome to print and fill out this form before coming in for your scheduled appointment. Thank you for choosing us as your dental care provider!
To make things easier for you, we welcome you to click on the PDF file to download, print, fill out and take with you to your next appointment.

Download "HS-welcome-form.pdf"

Our Financial Policy

Thumbnail 220x PDF
All patients are more than welcome to print out and sign our Financial Policy before coming in for your scheduled appointment. The policy is shown here for your convenience.

Download "HS-Financial-forms.pdf"

Notice Of Privacy Practices

Holly Springs Family Dentistry
Dr. Meredith D. Taylor, DDS, PA

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

If you have any questions about this Notice please contact the Privacy Officer.
919-290-2772

Effective Date: April 14, 2003                                                                                  Revised:  July 17, 2014

We are committed to protect the privacy of your personal health information (PHI).

This Notice of Privacy Practices (Notice) describes how we may use within our practice or network and disclose (share outside of our practice or network) your PHI to carry out treatment, payment or health care operations. We may also share your information for other purposes that are permitted or required by law. This Notice also describes your rights to access and control your PHI.

We are required by law to maintain the privacy of your PHI.  We will follow the terms outlined in this Notice.

We may change our Notice, at any time. Any changes will apply to all PHI. Upon your request, we will provide you with any revised Notice by:
 
  • Posting the new Notice in our office.
  • If requested, making copies of the new Notice available in our office or by mail.
  • Posting the revised Notice on our website: www.hollyspringfamilydentistry.com.