Drs. Perlman & Koidin, P.C.

(781) 599-2900
77 Broad Street
Lynn, MA 01902

Forms

We welcome you to our office and look forward to meeting you and your family. Part of the initial visit is to understand the medical history of our new patient. Please take the time to fill out the following forms and either mailed it or bring it to our office at the time of the first appointment. The patient registration form may be typed and then printed. If you have difficult typing your responses, please print the form and fill in your answers.

If the patient is under the age of 18

The parent or legal guardian must fill out the patient registration form. It is very important we understand your child’s medical history. Please bring the name(s) and dosage(s) of any medication currently prescribed. Please check with your child’s primary care physician if pre-medication (antibiotics) are required for dental procedures. Please be sure to fill out the insurance information and be sure to sign on the 3 red X’s.

Enclosed is our “Notice of Privacy Practices.” The federal government passed a law called HIPAA in 2002 protecting the privacy of patients and their health information. Please read our privacy policy and then fill out the “Acknowledgment of Receipt of Privacy Practices.” This form just acknowledges you received our privacy policy to read; it does not state whether you agree or disagree with the policy.

If your child has been to another dentist within the past year, please fill out the “Authorization for Release of Protected Health Information.” Please either mail or fax the form to your prior dentist in order for the records and x-rays to be transferred to our office by the time of your child’s first visit.

Patient Registration Birth to 18 Years of Age

Notice of Privacy Practices

Acknowledgment of Receipt of Notice of Privacy Practices

Authorization for Release of Protected Health Information

In an effort to prevent medical identity theft and to be in compliance with Massachusetts State Law 201 CMR 17.00, we will need a picture id from the parent or legal guardian (i.e. Driver's license, passport, etc.).

To view these forms you need Adobe Reader installed on your computer, to download it for free click here.

If the patient is 18 years of age or older

The patient or his/her legal guardian must fill out the patient registration form. It is very important we understand the patient’s medical history. Please bring the name(s) and dosage(s) of any medication currently prescribed. Please check with the patient’s primary care physician if pre-medication (antibiotics) are required for dental procedures. Please be sure to fill out the insurance information and be sure to sign on the 3 red X’s. If you are not accompanying the patient to his/her appointment or the patient lives in a group home or other facility and you want someone other than you to make appointments, accompany the patient to the appointment and speak to our staff regarding the patient, please be sure to fill out the “Authorization to Release Protected Health Information” section. This will allow our office to communicate with the person/facility accompanying the patient.

Enclosed is our “Notice of Privacy Practices.” The federal government passed a law called HIPAA in 2002 protecting the privacy of patients and their health information. Please read our privacy policy and then fill out the

Acknowledgment of Receipt of Privacy Practices.” This form just acknowledges you received our privacy policy to read; it does not state whether you agree or disagree with the policy. If the patient has been to another dentist within the past year, please fill out the “Authorization for release of protected health information.” Please either mail or fax the form to your prior dentist in order for the records and x-rays to be transferred to our office by the time the patient’s first visit.

Patient Registration

Authorization for Release of Protected Health Information

Notice of Privacy Practices

Acknowledgment of Receipt of Privacy Practices

To view these forms you need Adobe Reader installed on your computer, to download it for free click here.