Your Privacy: Information transmitted from this page is encrypted and secure. Your data will never be used by anyone other than your healthcare provider.
Patient Sign-in

Patient Information

Mark A. Skidmore, DDS

3059 Forest Hill Irene Road,
Germantown, TN 38138
(901) 754-2223

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
  •  Email
  •  Text Message
  •  Both
Responsible Party's Information( * mandatory to fill )
Emergency Contact Information( * mandatory to fill )
Primary Insurance Details( * mandatory to fill )
Medical History( * mandatory to fill )
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could h
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Pregnant/trying to get pregnant?
  •  Nursing?
  •  Taking oral contraceptives?
  •  Aspirin
  •  Pencillin
  •  Codeine
  •  Acrylic
  •  metal
  •  Latex
  •  sulfa drugs
  •  Local anesthetics
  •  Other
Do you have, or have you had, any of the following?
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

(Please click below to draw/upload sign)
(Your IP Address : IP:3.231.220.139 )
Cancellation Policy( * mandatory to fill )

Our desire is to provide you with the highest quality service and exceptional dental care in a caring and enjoyable atmosphere. We value your time and strive to maintain your appointment at the allotted time, in return, we request the same from you. We will need at least 24 HOURS notice to cancel or reschedule an appointment.

Unfortunately, as a result of the significant increase in short notice cancellations and disregard for appointment confirmations, it has become necessary for us to enforce the following policy.

Failure to provide adequate notice may result in the following:

  •  If you are more than5-7 minutes late for your appointment, it may be necessary for you to be reschedule and that appointment could be considered a cancellation without adequate notice. PLEASE call if you feel you may arrive later than your scheduled appointment time so that our team can make accommodations to see you.
  •  a $25.00 fee MAY be accessed to your account and must be paid before being rescheduled.
  •  Single patient scheduling, only one family member scheduled at a time, If multiple appointments are failed within the same day.
  •  As a last resort and after MANY failed attempts to schedule appointments, we may have no choice but to dismiss your care from the practice.

**Thank you for your understanding that we are committed to being available to ALL our patients who need dental care.

** I HAVE READ AND UNDERSTAND THE POLICIES ABOVE:

(Please click below to draw/upload sign)
(Your IP Address : IP:3.231.220.139 )
Receipt of Notice of Privacy Policies( * mandatory to fill )

Your Privacy Is Important to Us

Acknowledgement of Receipt of Notice of Privacy Policies

I have received a copy of the Notice of Privacy Practices of M Skidmore D.D.S. I hereby authorize, as indicated by my signature below, to use and to disclose my protected health information for any necessary clinical, financial, and insurance purpose, as authorized in the Patient Consent form.

(Please click below to draw/upload sign)
(Your IP Address : IP:3.231.220.139 )
  •  You may contact me at my home telephone number
  •  You may contact me on my mobile telephone number
  •  You may contact me on my work telephone number
  •  You may send me an email at
  •  Other

Please list authorized persons with whom we may discuss your Protected Health Information (PHI) in addition to custodial parents and legal guardians:

Copyright ©2020
Your browser doesn't support signing