Patient Forms

COVID-19 Release Form

In order to reduce the risk of spreading COVID-19, all patients are required to fill out a COVID-19 Release Form which asks a few simple screening questions about the common symptoms of the virus and any recent travel. One of these forms will be required every time you come in for treatment, to account for the possibility of symptoms developing between appointments.

If you are exhibiting symptoms of COVID-19, we will put your appointment on hold until you are symptom-free for 14 days.

You may fill this form out online and submit it to us directly through our website, or if you prefer you may download the form below. For your convenience, the form is available in Adobe PDF and Microsoft Word formats.

If you choose to download the form, you may return it to us quickly by emailing a scanned or electronically signed copy to frontdesk@randdental.com. Please include your name or the patient's name in the email.

Online Patient Forms

If you are a new patient, you can fill out our registration forms online ahead of your appointment. The forms will be securely submitted to our server. When you arrive for your appointment please let the front desk staff know that you filled out your forms online. You will be asked to electronically sign these forms in our office in person.

Electronic Forms for New Patients

Existing patients can update their forms online. Updating forms requires that you sign in to our Patient Account Access Portal, or first registering for an account if you do not have one. You can find more information here.

Patient Account Access Login

Printable Patient Forms

If you would prefer, you may print your registration forms to fill out ahead of your visit, rather than filling them out online.

  • New Adult Patient Form
  • New Pediatric Patient Form
  • Consent to Share Confidential Medical Information

If the patient is a minor and must be accompanied to the office by someone who is not a parent or guardian, then please fill out and provide us with the following form to document your consent.

  • Authorization For a Designated Adult to
    Consent For and Accompany a Minor Patient
    (PDF File is in English y en español)

The following forms are informative and do not need to be signed or presented in office. Rather, they are provided here so that you may download a copy for your records.

If you are unable to open and view PDF files, you can download Adobe Reader® for free to view them.