Patient Information
If you have dental insurance through someone else other than yourself, please provide their information below:
MEDICAL HISTORY
Please list any prescription / over the counter medications you are taking:
I have received a copy of Dr. Keeter / Geiger / Ellsworth's Notice of Privacy Practices and have read and understand this information.
By signing this form, you have reviewed and understand our Notice of Privacy Practices and give consent to use and disclose your protected health information that may be used for treatment, payment or healthcare operations.
We reserve the right to change the privacy policy as allowed by law. You have the right to revoke this consent in writing at any time and all full disclosures will then cease.
If YES, please list names below: