Let’s get you started!

We value your time. So we’ve made our new patient forms available to you below to complete at your convenience before your first visit. You can fill these out and fax or email prior to your appointment, or bring the completed forms with you.
 

Contact Info

Cynthia N. Elderkin DDS, PA
8015 Creedmoor Rd # 202
Raleigh, NC 27613
Phone: 919-847-8747
Fax: 919-847-8747
Email: info@secure.cynthiaelderkindds.com

 
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Medical History Form

This is a confidential health history form in which we get needed information to provide you and your family with the best care.

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Release Of Records

This is a transfer release form to get dental records sent to Cynthia N. Elderkin DDS. from another dental practice.

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Authorization for Release of Personal Health Information

This form allows you to define with whom Cynthia N. Elderkin DDS. can share your protected health information.

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notice of Privacy Practices/HIPAA Acknowledgment

This notice describes how health information about you may be used and disclosed and how you can get access to this information.

 
 

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