Patient Forms

Please print, complete, sign, and return the following four required pages prior to your new patient appointment:

•	New Patient Registration (Required)
•	New Patient Medical History (Required)
•	Financial Policy (Required)
•	HIPAA Privacy Practices - Acknowledgement to Sign (Required)
•	Notice of HIPAA Privacy Practices
•	Release of Information Authorization - Optional

•	Instruction for Night Guard Care
•	Instructions for KOR Overnight Bleaching
•	Postoperative Instructions for Extractions
•	Postoperative Instructions for Extractions with Bone Graft
•	Postoperative Instructions for Dental Implants
•	Liquid Diet Suggestions
•	Blender Ideas
•	Oral Sedation Instructions

Dr. Jessica Mintie Kloenne
Dr. Robert A. Leon
Mintie Family Dentistry

511 SW 10th Ave. #804
Portland, OR. 97205

info@mintiefamilydentistry.com

Hours:
M: 9am–6pm
Tu–Th: 7am–4pm
F: by appt. only

Getting Here:
We validate at Smart park on 10th Map

Max street car line accessible.
Tri-Met Stop ID 8384