Patient Forms

For your convenience, we have supplied an online Health History Form. If you wish, click on the link below, complete the form at home, and submit it. You may also complete the HIPAA form as well. This will save processing time when you arrive at the office. We look forward to greeting you in person!

Beginning April 14, 2003, providers such as Fountain Square Cosmetic Dental Group are required by the Health Insurance Portability and Accountability Act to present the following information to all patients.  Please take the opportunity to read, review and sign each of the following documents prior to your next appointment. Doing so will expedite the process and lessen your waiting time when you arrive at our office.


Effective June/12/2003

Our Commitment To Privacy

Your privacy is important to us. To better protect your privacy, we provide this notice explaining our online information practices and the choices you can make about the way your information is collected and used. To make this notice easy to find, we make it available on our homepage and at every point where personally identifiable information may be requested.

The Information We Collect

This notice applies to all information collected or submitted on the Fountain Square website. On some pages, you can make requests and register to receive materials. The types of personal information collected at these pages are:

Email address
Phone number

The Way We Use Information:

We use the information you provide about yourself to answer your questions and provide you with information. We do not share this information with outside parties.

We use return email addresses to answer the email we receive. Such addresses are not used for any other purpose and are not shared with outside parties.

Finally, we never use or share the personally identifiable information provided to us online in ways unrelated to the ones described above without also providing you an opportunity to opt-out or otherwise prohibit such unrelated uses.

Our Commitment To Data Security

To prevent unauthorized access, maintain data accuracy, and ensure the correct use of information, we have put in place appropriate physical, electronic, and managerial procedures to safeguard and secure the information we collect online.

Our Commitment To Children's Privacy

Protecting the privacy of the very young is especially important. For that reason, we never collect or maintain information at our website from those we actually know are under 13, and no part of our website is structured to attract anyone under 13.

How To Contact Us

Should you have other questions or concerns about these privacy policies, please call us at (513) 621-BITE (2483) or contact us. .