Patient Registration

Clarke V. Filippi, DDS – Modesto & Central Valley CA

Online Forms

On behalf of Dr. Filippi and all of our team, we welcome you to our practice. Thank you for giving us the opportunity to provide you with the highest quality periodontal and dental implant care.

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.

Online Registration Form (s)

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.

Print General Release

Print Patient Information Questionnaire

Print Health History

Federal law requires all medical offices to comply with HIPAA regulations. Please read the link to important HIPAA information:

Print Notice of Privacy Practices

Once you have done this please print out and complete the following form:

Print HIPAA Acknowledgement and Consent

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.

 

Periodontist Clarke V. Filippi, DDS is a specialist in periodontics and implantology. Call our office today!
Modesto Office Phone Number 209-572-6008 Request an Appointment Map & Directions