Bradley S. Roberts, DDS Eugenia P. Roberts, DDS & Associates, Inc.
11907 Montgomery Road, Suite B
Cincinnati, Ohio 45249
tel: (513) 697-1211
fax: (513) 697-1214
email: michelle@robertsdentalgroup.com

Forms




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What Our Patients Are Saying


Patient Forms

New Patient Information Form
New patients can save time on their first office visit. Just print and complete the New Patient Information Form and bring all 4 pages to your first visit or fax to 513-697-1214.

The office HIPAA and privacy notice is below. You may also request a copy at our office.

If you are a non-English speaking patient, please go to http://dental.pacific.edu/DentalPro/Health_History_Forms
/default.htm
to print a health history form in your native language. Please bring this with you to your first visit.

Roberts & Roberts, DDS Brochure
For a printable color copy of our brochure click here.


What Our Patients Are Saying


HIPAA Notice

Click here for a printable copy of our HIPAA Notice describing our practice's patient privacy policy about how your medical/dental information may be used and disclosed.

Patient Survey Form


Please use this form to comment on your dental visit.

Any comments you choose to make are kept strictly confidential and can only help us improve our VIP (very important patient) service.


Full Name*


Email Address*


Did our receptionist greet you properly?
yes    no    I do not recall

Did you wait over 15 minutes past your appointment time to be seated?
yes    no    I do not recall

Were you offered any of our "TLC" amenities? (please choose all that apply)
beverage bar    warm neck wrap    TV    music headphones   
complimentary relaxation massage

Did you enjoy the TLC amenities?
yes    no    not applicable

Did any staff member go above and beyond our normal service level to assist you during your appointment? If so, please tell us how and who.

Please comment on how we could make your visit better, new services you would like to see, or other ways we can make you feel more comfortable.

Press the Submit button to send your message!

       

Roberts & Roberts, DDS Website Privacy Policy

Roberts & Roberts, DDS is committed to providing quality service to meet all the needs of its patients. One of the newest and fastest growing delivery channels is the Internet. A concern arising from the rapidly changing world of technology and specifically the Internet, is your right to maintain privacy. We assure you that we share your concerns and are committed to ensure that all information you supply us is held in strictest confidence. Visitors to Roberts & Roberts, DDS's web site will remain anonymous. We do not collect personal identifying information about visitors to our site. If you provide identification (such as name and address) via email or online form, or ask for information, the information provided will only be used to communicate with you to handle your request. It is not sold or transferred to other parties. Our servers only collect standard non-identifying information about visitors to the site, such as date and time visited, IP address, city, state and country. This information is used to compile standard statistics on site usage.

Click here for our HIPAA notice describing our practice's patient privacy policy about how your medical/dental information may be used and disclosed.


Cosmetic Dental Designs
Bradley S. Roberts, DDS Eugenia P. Roberts, DDS & Associates, Inc.
11907 Montgomery Road · Suite B · Cincinnati, Ohio 45249
tel (513) 697-1211 · fax (513) 697-1214 · email: michelle@robertsdentalgroup.com

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Copyright 2006. All Rights Reserved. Roberts & Roberts, DDS, Inc.