Patient Forms

Please print, fill out, and bring the following three forms in with you to your appointment.


Medical History Form:

  MND_Medical History

Financial Policy:

  MND Financial Policy

HIPPA Acknowledgement:

  MND HIPPA Form

Click here to read Moreland Neighborhood Dental’s Notice of Privacy Practices.


Release of Records:

*Print and sign this only if you would like for our office to request your dental records from your previous provider.

MND Authorization To Release Records

HIPPA Consent to Receive Text Messages:

 MND HIPAA Text Authorization 

6200 SE Milwaukie Avenue

Portland, OR 97202

503-235-7000

Call us today!

Office Hours

Mon-Thurs: 7:00am-5:00pm Fri: 7:00am-4:00pm

Schedule Appointment

smile@morelanddental.com
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