Patient Forms

Name *
Parent/Guardian Information (Fill out, if patient is a child)
Parent/Guardian Information (Fill out, if patient is a child)
Format 01/01/2000
Address *
Home Phone *
Home Phone
If none, N/A
Preferred Contact Method *
How did you hear about us?
If you referred by someone, we would like to thank them!
Last name, First name, MI, Birthday, Best phone. If same, please enter 'Same'
N/A for none
Please check if you are allergic to any of the following: *
Please check if you have any of the following medical conditions:
or N/A
By submitting this form, I acknowledge that I have received and understand Preferred Dental's Notice of Privacy Practices, Cancellation Policy and Financial Policy.

Notice of Privacy Practices




We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our Privacy Practices, out legal duties, and your rights concerning your information. We must follow the Privacy Practices that are described in this Notice while it is in effect. This Notice takes effect July 27, 2018, and will remain in effect until we replace it.

We reserve the right to change our Privacy Practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our Privacy Practices and the new terms of our Notice effect for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our Privacy Practices, we will change this Notice and make the new Notice available upon request.

You make request a copy of our Notice at any time. For more information about our Privacy Practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.


We use and disclose health information about you for treatment, payment and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our health care operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights Section of this Notice. We may disclose your health information to a family member, friend or other person to extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification or (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death, If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In event of your incapacity or emergency circumstances, we will disclose health information based on a determination use in your professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorize federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institutions or law enforcement officials having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as phone calls, voicemails, emails, text messages, postcards, or letters).



Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other that photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $25.00 for x-ray copies and $0.25 for each copied page of your health information. Postage may be charged if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before February 1, 2017. If you request this account more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. {You must make your request in writing.} Your request must specify the alternatives means or location, and provide satisfactory explanation how payments will be handled under these alternatives means or location requests.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Website or by electronic mail (e-mail), you are entitled to receive this Notice in written form.



If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternatives locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Humans Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.


Provider Contact Office: PREFERRED DENTAL


Office Manager: EVANN COX

Telephone: 719-445-0827 Fax: 719-645-8432



Cancellation Policy

Our appointments are held especially for you, due to the nature of our services and the demand for appointments we require 24 hour notices to cancel or reschedule any appointments.

If you cancel or reschedule more than 2 appointments after the 24 hour window, you will be moved to our patient waitlist; which requires that you have walk in appointments and pay all fees before any appointment.

If you ‘no show’ to more than 2 appointments we will no longer be able to have you as our patient.

We value you as a patient and reserve time in our schedules to provide you with the care that you need. Broken appointments without 24 hour notice are assessed a $25.00 broken appointment fee since this time was reserved for you and otherwise could have been used to treat another patient  in need. (The broken appointment fee does not apply to patients with Medicaid/Health First Colorado

Financial Policy

Thank you for choosing Preferred Dental. We appreciate you as a patient, and want you to be familiar with our financial policies.

Dental insurance plans do not normally provide full coverage of your dental bill. Any dental coverage you have is a contract between you and your insurance company and it is important that you take the initiative to understand that contract, its benefits and its limitations. As a service to you we aim to help you understand and file your insurance claims, and while we will cooperate to the fullest in expediting your claim, you are ultimately responsible for your account with us. Please remember that estimates given through our office are NOT a guarantee of payment by your insurance company. Your portion of the total bill will be due at the time of service.

Any bill that is not paid at the time of service will receive a 10% weekly interest after 60 days of no payment.

After 90 days of no payment, your account will be turned over to collections. All costs of collection of the account including, but not limited to, 18% interest, re-billing fees, court costs, attorney fees, and collection agency costs of 40% are the responsibility of the patient and/or the responsible party.

Any declined credit card will receive a $15.00 declined card fee. Any returned checks with be charged a $30.00 returned check fee. All fees are due before any further services are rendered. Any account that has gone past due will be required to pre-pay for further services.