Patient forms
If you are a new patient to our office, you can download & print the new patient forms that will need to be filled out when you arrive at our office. Filling them out ahead of time and bringing them with you will speed up the process and allow us to attend to your dental needs more quickly than completing them on your arrival. We can also mail you these forms upon request.
Thank you and please call our office if you have any questions at all.
*This is for you to read over & keep and does not need to be brought into the office. *Print & fill this out and bring it into our office at the time of your appointment. -
Discrimination is Against the Law
Ashland City Dental complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Ashland City Dental does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Ashland City Dental:
Provides free aids and services to people with disabilities to communicate effectively with us, such as:
Qualified sign language interpreters
Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as:
Qualified interpreters
Information written in other languages
If you need these services, contact Rafael Zavala - Office Manager
If you believe that Ashland City Dental has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
Rafael Zavala, Office Manager
615-235-5144
info@ashlandcitydental.com
189 Monroe Place
Suite 104
Ashland City, TN 37015Service A. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Rafael Zavala, Office Manager is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 202011-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.