Patient Forms
The law requires us to give each patient a Notice of Privacy Practices. This tells the patient what your rights are as a patient.

Each patient must sign a form acknowledging that we provided them with a Notice of Privacy Practices. It is the Acknowledgement of Receipt of Privacy Practices form. This is kept in the patient's file.

Each patient must sign a Consent for Use and Disclosure of Health Information form. This is also kept in the patient's file.

Use Our Online Forms and Save Time
You may fill out and submit these forms on our Web site! Or, if you have concerns about providing information via the internet, fill them out, and print them prior to an appointment. Then bring them with you to your first visit to save time when you arrive.

Notice of Privacy Practices
Acknowledgement of Receipt of Privacy Practices
Consent for Use and Disclosure of Health Information
Patient Information Form
Medical History

Robert C. Doshier, D.D.S., P.A. • 125 Sisco Street, Harrison, Arkansas 72601 • (870) 741-8551
E-mail: bdoshier@doshierdds.com • www.doshierdds.com

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