Marketplace Smiles
Patrick Bell, DDS & Associate Hal Moore, DDS
Call: (512) 868-5000

Patient Forms

 NEW PATIENTS-

The first visit to our office is designed to get you better acquainted with all we offer as well as introduce you to our Doctor and our caring staff. We encourage questions and do our best to always deliver quality care.

Please take a moment prior to your scheduled appointment to download our patient forms. We ask that you complete the forms and bring them with you to your appointment along with a current medication list, so we may better assist you in a timely manner. 

Thank you for your confidence in our office, we look forward to assisting you with all your dental needs.

New Patient Forms Link

Acknowledgement of receipt of notice of privacy practices.pdf 

Acknowledgement of Receipt, Consent, Use, Disclosure of PHI.pdf 

EXISTING PATIENTS-

Patient Login Link

IF YOU ARE LEAVING US- 

Please fill out this form if you are leaving our practice and would like our office to release your records to another entity. To expedite the release please provide an email address to the new entity that they prefer records to be sent to.

Pt Authorization to Release Records. pdf


This web site uses files in Adobe Acrobat Portable Document Format (pdf) which require Adobe® Acrobat® Reader for viewing and printing. It is available to download free.

 

Contact Us

We encourage you to contact us with any questions or comments you may have. Please call our office or use the quick contact form below.
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