FORMS
Please click on one of the following forms in order to download it:
- New Patient Registration
- New Patient Medical & Dental History
- Patient of Record Health History Update
- purpose of this form is to transfer your dental x-rays taken at
another dental or medical office to Goodyear General Dentistry.
Please provide us with your previous dental office fax number or
address so we can provide that office with your request. You may
also want to check with that office regarding any record transfer
fees that must be paid before your x-rays are released.
- purpose of this form is to release your dental x-rays taken at our
office to another dental or medical office of your choice. Per our
office privacy practices & HIPPA and in order to protect our
patients privacy, this form must be completely filled out, signed,
and dated. Please fax or mail this form to our office. Average
processing time in order to release your x-rays is 7 business days.
Please note the X-ray Duplication fee is $20.00 per Arizona State
Law.
Click on MAKE A PAYMENT button in order to pay the x-ray
duplication fee. Thank you,
© 2005 COPYRIGHT All Rights Reserved GOODYEAR GENERAL DENTISTRY, P.C. SAMER SAFADI, D.D.S., M.S. |
GOODYEAR GENERAL DENTISTRY
SAMER SAFADI, D.D.S., M.S.
SAMER SAFADI, D.D.S., M.S.
1616 N. Litchfield Rd, Ste 150 Goodyear, Arizona 85338 Phone (623) 536 0044 e-mail: dentist@ssafadi.com |
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