Patient Registration

We look forward to meeting you and helping you achieve your dental goals. In anticipation of your initial appointment at our office, you may download the Patient Information, Consent for Use and Disclosure of Health Information, and Medical History forms and complete at your convenience. Please remember to bring the forms with you to the appointment.

Privacy Policy

This form, Notice of Privacy Practices, presents the information that federal law requires us to give our patients regarding our privacy practices.

This notice is a pdf document which requires the Adobe Reader software. You most likely already have this software on your computer. However, if you have difficulty reading the notice, please click here to install Acrobat Reader.

Notice of Non-discrimination

Pioneer Periodontics & Implant Dentistry, PC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Pioneer Periodontics & Implant Dentistry, PC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. 

Pioneer Periodontics & Implant Dentistry, PC

  •   Provides free aids and services to people with disabilities to communicate effectively with us, such as:

             o   Qualified sign language interpreters

             o   Written information in other formats (large print, audio, accessible electronic formats)

  •    Provides free language services to people whose primary language is not English, such as:

             o   Qualified interpreters

             o   Information written in other languages. If you need these services, contact Diane Harris

If you believe that Pioneer Periodontics & Implant Dentistry, PC 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 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. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

We will take reasonable steps to provide free-of-charge language assistance services to people who speak languages we are likely to hear in our practice and who don’t speak English well enough to talk to us about the dental care we are providing.

Spanish:

Tomaremos acciones razonables para proporcionar servicios de asistencia lingüística gratuitos a aquellas personas cuyo lenguaje escuchemos frecuentemente en nuestro consultorio y que no hablen un inglés lo suficientemente bueno como para hablar con nosotros sobre el servicio odontológico que suministramos.

Vietnamese:

Chúng tôi sẽ thực hiện các bước cần thiết để cung cấp dịch vụ hỗ trợ ngôn ngữ miễn phí cho những người giao tiếp bằng những ngôn ngữ mà chúng tôi có thể nghe thấy tại phòng khám của mình và cho những người không có đủ trình độ tiếng Anh để thảo luận về dịch vụ chăm sóc nha khoa mà chúng tôi đang cung cấp.

Chinese: 们将有序地做到提供免言服使我能听懂英不好的人向我有关牙齿护

Arabic:

سوف نقوم باتخاذ خطوات معقولة من أجل توفیر خدمات المساعدة اللغویة بدون تكلفة للأشخاص الذین یتحدثون لغات أخرى من المرجح أن نستمع إلیھا خلال ممارستنا والذین لا یتقنون تحدث الإنجلیزیة بشكل جید یمكنھم من التحدث إلینا فیما یتعلق برعایة الأسنان التي نقدمھا.

Karen:

French:

Nous prendrons les mesures raisonnables pour fournir des services d’assistance linguistique gratuits pour les individus qui parlent des langues que nous sommes susceptibles d’entendre durant nos séances et qui ne parlent pas suffisamment bien l’anglais pour discuter avec nous concernant les soins dentaires que nous fournissons.

Cushite (Oromo):

Wayita hojjii keenyatti Afaanota garaa garaagaraa namoota dubbatani fi tajaajila yaalaa nuti kenninuuf kan nu dandeessisu namoota dandeettii Aaan Ingilliffaa gahaa ta’e hin qabneef deeggarsa afaanii kanfaltii irraa bilisa ta’e kennuudhaaf tarkaanfii bu’a qabeessa ta’e ni fudhanna.

German:

Wir werden angemessene Schritte unternehmen, um denen eine gebührenfreie Sprachunterstützung zu bieten, die Sprachen sprechen, die wir möglicherweise in unserer Praxis hören, die aber kein Englisch sprechen, das gut genug ist, um mit uns über die Zahnpflege zu sprechen, die wir anbieten.

Korean:

저희는 적절한 조치를 통하여 언어 지원 서비스를 무료로 제공할 것입니다. 다만, 실제로 저희에게 관심이 있는 언어를 쓰지만 저희 치아 관리 서비스에 대해 의견을 줄 수 있을 만큼 영어로 의사소통이 원활하지 않는 경우로 한정합니다

Nepali:

Russian:

Мы принимаем необходимые меры, чтобы предоставить бесплатные услуги переводчика для общения на языках, с которыми мы сталкиваемся в нашей практике с клиентами, которые не владеют английским языком достаточно, чтобы обсудить с нами стоматологическое обслуживание, которое мы предоставляем.

Laotian:

ພວກເຮົາຈະໃຊ້ຂັ້ນຕອນທີ່ເໝາະສົມເພື່ອໃຫ້ບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາບໍ່ເສຍຄ່າແກ້ຄົນຜູ້ທີ່ເວົ້າພາສາທີ່ພວກເຮົາອາດຈະໄດ້ຍິນຢູ່ໃນການຝຶກຊ້ອມຂອງພວກເຮົາແລະຜູ້ທີ່ບໍ່ເວົ້າພາສາອັງກິດໄດ້ດີພໍເພື່ອລົມກັບພວກເຮົາກ່ຽວກັບການເບິ່ງແຍງດູແລແຂ້ວທີ່ພວກເຮົາກໍາລັງຈັດໃຫ້.

Kurdish:

ھھنگاوی گونجاو دەگرینھبھر بۆ پێشکھشكردنی خزمھتگوزاری بھخۆڕایی یارمھتی زمان بۆ ئھو کھسانھی زمانی تر قسھ دەکھن و ئینگلیزی باش نازانن بۆ

قسھکردن لھگھڵ ئێمھ دەربارەی چاودێری ددان کھ پێشکھشی دەکھین.

Persian (Farsi): ما برای ارائھ خدمات ترجمھ رایگان بھ افرادی کھ زبان انگلیسی آنھا برای صحبت با ما درباره خدمات مراقب از دندان ارایھ شده ما در حد

کافی نبوده و بھ زبان ھای صحبت می کنند کھ ما بھ احتمال زیاد در ھنگام کار با آنھا سر و کار پیدا می کنیم گام ھایی منطقی را بر خواھیم

داشت.

Japanese: 実際練習にするく可能性がある言語人々で、弊社提供している歯科治療について、英語がそれほど上手でない人々に、無償言語支援ビスを提供するために合理的措置じるつもりです。