Patient Forms


You may access the following forms to assist us with your care. Please complete the following forms, and click the "Submit" button at the bottom of each form.

Non-Discrimination and Language Assistance Notice‚Äč

Discrimination is Against the Law

Rock Dental Brands complies with applicable federal and state civil rights laws and does not discriminate, exclude, or treat people differently on the basis of race, color, national origin, age, disability, or sex.

We provide free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters, written information in various formats (large print, audio, accessible electronic formats, other formats), and language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. 

If you need these services, contact Paul D. McNiel, Director of Dental Operations in advance.

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
[email protected]

You can file a grievance in person or by mail, fax, or email.  If you need help filing a grievance, Paul D. McNeil, Director of Dental Operations is available to 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:, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue SW., Room 509F, HHH Building
Washington, DC 20201
Phone: 1-800-368-1019; TDD: 1-800-537-7697

Complaint forms are available at