Patient Forms

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You may access the following forms to assist us with your care. Please complete either the electronic new patient packet and submit online or print the PDF packet and bring with you to your appointment. This ensures we will be prepared as possible for your first appointment.

 

Non-Discrimination and Language Assistance Notice​

Non-Discrimination Policy

DISCRIMINATION IS AGAINST THE LAW
Rock Dental Brands complies with applicable Federal civil rights laws and does not discriminate on the basis
of race, color, national origin, age, disability, or sex. Rock Dental Brands does not exclude people or treat
them differently because of race, color, national origin, age, disability, or sex.
Rock Dental Brands:

Provides free aids and services to people with disabilities to communicate effectively with us, 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, contact Paul D. McNiel, Director of Dental Operations.

If you believe that Rock Dental Brands 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:

Paul D. McNiel, Chief Compliance Officer
610 Clinton Ave. Little Rock, AR. 72201
501-259-8331
paul.mcniel@rockdentalbrands.com.

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Paul D. McNiel, Director of Dental Operations 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:

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 .