Patient Information & Registration Forms

Patient Registration Policies
(Includes: Patient Appointment Agreement, Financial Policy, General Policies and Initial Consent, Patient Rights and Responsibilities, and Notice of Privacy Practices)

Patient Registration Packet
(Agreement that patient signs, acknowledging their agreement to the Patient Registration Policies above as well as consent to electronic communication, teledentisty consults, the e-prescribe program.)

PHI Use or Disclosure Form
(Authorization for use or disclosure of protected health information for records, reports, x-rays, etc.)

Referral Form
(Authorization for referral form for external providers to refer to ECU SoDM)

Notice of Privacy Practices

Notice to Patients (English)

Prácticas de Privacidad (Spanish)

Discrimination is Against the Law

East Carolina University School of Dental Medicine complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.  East Carolina University School of Dental Medicine does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

The ECU School of Dental Medicine:

  • Provides free aids and services to people with disabilities, 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 at any of our locations, contact the Call Center Supervisor, 252-737-7169 or call the Department for Disability Support Services, 138 Slay Building, Greenville, NC 27858-4353 or phone 252-737-1016 voice/TTY.

If you believe that East Carolina University School of Dental Medicine 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:

East Carolina University Department for People Operations, Success, and Opportunity
Old Cafeteria Building Suite G406
Mail Stop 104
Greenville, NC 27858
Phone: 252-328-6804
Email: oed@ecu.edu

You can file a grievance online at Equal Opportunity and Title IX Concerns & Complaints, in person or by mail, or email. If you need help filing a grievance, the Department for People Operations, Success, and Opportunity 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 Complaint Portal Assistant 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. 20201; 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at Complaint-Process.

Please be advised, Section 1557 notice is the nondiscrimination provision of the Affordable Care Act (ACA) which is limited to race, color, national origin, age, sex, and disability.  East Carolina University prohibits unlawful discrimination based on the following protected classes: race/ethnicity, color, genetic information, national origin, religion, sex (including pregnancy and pregnancy related conditions), sexual orientation, gender identity, age, disability, political affiliation, and veteran status.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 252-737-7169.

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 252-737-7169 。

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 252-737-7169.

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 252-737-7169 번으로 전화해 주십시오.

ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 252-737-7169.

ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم 252-737-7169 رقم .

LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 252-737-7169.

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 252-737-7169.

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 252-737-7169

ચુ ના: જો તમેજરાતી બોલતા હો, તો િન:લ્કુ ભાષા સહાય સેવાઓ તમારા માટઉપલબ્ધ છ. ફોન કરો 252-737-7169

្របយ័ត៖ េបើសិនអកនិយ ែខ រ, េសជំនួយែផក េយមិនគិតឈ ល គឺចនសំប់បំេរ អក។ ចូរ ទូរស័ព 252-737-7169

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 252-737-7169.

ध्यान द: यद आप हदी बोलते ह  तो आपके िलए मुफ्त म भाषा सहायता सेवाएं उपलब्ध ह। 252-737-7169.

ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາ, ໂດຍບໍ່ເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 252-737-7169

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。252-737-7169