Patient Forms

 

The Rector Dental Group has always put their patients first, making sure they leave with a smile.  To make the new patient process easier for you and so you can be in and out of the office quickly, please fill out the new patient forms that are attached and bring them into the office with you on your first visit.

HHS Office for Civil Rights

The Rector Dental Group complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Rector Dental Group does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

The Rector Dental Group

  1. 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)
  1. 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 our office at 765-286-4017.

If you believe that The Rector Dental Group 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 office manager of The Rector Dental Group, 3905 N Wheeling Ave. Muncie, IN 47304, or drjeffrector@comcast.net.  You can file a grievance in person or by mail, fax, or email.  If you need help filing a grievance the office manager 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 Ave. SW Room 509F, HHH Building, Washington, DC 20201, 1-800-868-1019, 800-537-7697 (TDD).

Complaint forms are available at: https://www.hhs.gov/ocr/office/file/index.html.