(402) 502-1256

Health Forms

Health History, HIPAA Notice of Privacy Practices, and HIPAA Consent and Acknowledge form


The Health Form is in a writeable PDF format. Must fill in and bring to office. PPD_patient_history.pdf

HIPAA Notice of Privacy Practices — Must read!  HIPPA OMNIBUS Rule.pdf

HIPAA Aviso de prácticas de privacidad – Debe leer! HIPAA Omnibus Regla.pdf

HIPAA Consent and Acknowledgement Form is in a writeable PDF format. Must fill in and bring to office.

Papillion Pediatric Dentistry HIPPA Consent Form.pdf


Note: You may use your computer to complete the forms and then print them, sign, and bring the forms to the office (preferred). Or you may print the blank forms and fill them in using a pen, sign and bring the form with you to the office.