Timothy W. Godsey, Periodontics

Download Patient Forms or Fill Out Forms Online

For your convenience all the forms that will be needed for your first visit may be completed on-line and submitted to our office or you may download the forms, complete them at home and bring them with you to the consultation appointment.

Should you choose to compete your forms online, you will be automatically connected a server which is secure and regulated by all HIPAA requirements. Upon completion of online forms you will be immediately returned to this server.

Please keep in mind if you complete the forms on-line you will still be required to sign the forms when you come in for your first appointment.

Note that due to new security regulations we are now required to obtain a copy of the patient's photo id for our records. We request you bring appropriate photo id to your first appointment.

Fill Out Forms Online

Click here to fill out patient registration, medical information and Notice of Privacy Practice forms online.

Please note we have taken all reasonable steps to protect the information you are sharing with us.

Download Forms

If you prefer, you may click the links below to download the forms in PDF of JPEG format and bring them to your first visit.

Form Name PDF Format DOC Format JPEG Format
 
Patient Information/Medical Information Form As a pdf As a doc Page 1 as a jpeg [312k]
Page 2 as a jpeg [294k]
 
Release of Health Information Form As a pdf As a doc As a jpeg[1.182 meg]
 
Permission to Release Records to Family Member As a pdf As a doc As a jpeg [184k]
 
Notice of Privacy Practices As a pdf As a doc Page 1 as a jpeg [520k]
Page 2 as a jpeg [595k]
 
Acknowledgment of Receipt of Privacy Practices As a pdf As a doc As a jpeg [142k]

Please note that a pdf file requires a pdf reader such as the free reader from Adobe. If you do not already have Adobe Reader installed on your computer, you may download it here. The jpeg versions may be opened in any program which can view images, but be aware the files are larger than the pdf versions and you may need to adjust their printer settings for best results. The Word version of the .doc files is Word 97-2003.