The completed forms can be mailed to:
JELOKHANI & ASSOCIATES, DDS, PA, 601 TUCKER STREET,
RALEIGH, NC 27603 or faxed to (919) 835-9305.
In the event that you have any questions or concerns please
do not hesitate to contact
JELOKHANI & ASSOCIATES, DDS, PA at (919) 833-8100.
Click here to download the ADULT
HEALTH HISTORY QUESTIONNAIRE
Click here to download the CHILD
HEALTH HISTORY QUESTIONNAIRE
Click here to download the ACKNOWLEDGEMENT
Click here to download the NOTICE
OF PRIVACY PRACTICES
Click here to download the CONSENT
FOR USE AND DISCLOSURE OF HEALTH INFORMATION
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Acrobat Reader installed on your computer.
If you don't have the Adobe Acrobat Reader installed
on your computer, please click here:
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