Perfecting Smiles in Southern Oregon

Contact Info

Bruce P. Mitchell, D.M.D.
Family Dentistry
3560 National Drive, Ste 102
Medford, Or 97504

(541) 773-3959
Fax: (541) 773-1186

Our Location

Testimonials

Everything about this office shines, from the free coffee in the foyer, to the bill pay. The staff treated me with superior service. As to the work of the dentistry itself, the staff was beyond competent. The office is equipped with the latest gizmos to help clean and protect your teeth – plus they could explain everything in great detail. My dentist, Dr. Prins, was very knowledgeable and showed a real passion for his...

David G.

See more

Patient Consent Form

Patient Consent form

I understand that, under the Health insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

  • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
  • Obtain payment from third-party payers.
  • Conduct normal healthcare operations such as quality assessments and physician certifications.

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

Click here to download a printable PDF.

You may sign this and bring it in on your scheduled appointment.