Clarke V. Filippi, DDS – Modesto & Central Valley CA
Completion of the necessary forms prior to your examination appointment will make your visit more efficient. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information. On your first visit to our office, we will have your completed form available for your signature. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.
Or if you prefer you may print out and complete the following forms which allow us to establish accurate information for your records. Do not forget to bring the forms with you.
Federal law requires all medical offices to comply with HIPAA regulations. Please read the link to important HIPAA information:
Once you have done this please print out and complete the following form:
Again, do not forget to bring the all four completed forms with you!
If you have dental insurance, please bring your most up-to-date insurance information with you.
If there is anything we can do to assist you prior to your first visit, please call our office ahead of time.