727-799-6733 28469 US 19 N #401, Clearwater, FL 33761

We include a list of all of the forms and documents that are included in our New Patient Packet.

Dr, Churney has placed these forms online so you have the opportunity to reference them, to read over them before your first appointment, or even print them ahead of time and fill them out.

These forms will always be available to you in our office and there will always be a staff member available to go over the information with you if you have questions or need assistance with the forms.


New Patient Packet


Directions / Map 


Notice of Privacy Practices / HIPAA


Click here to view HIPAA Policy Online
HIPAA, which stands for the American Health Insurance Portability and Accountability Act of 1996, is a set of rules to be followed by doctors, hospitals and other health care providers. HIPAA took effect on April 14, 2006. HIPAA helps ensure that all medical records, medical billing, and patient accounts meet certain consistent standards with regard to documentation, handling and privacy.


Churney Periodontics Office Location

Take US 19 South. Go 1.25 miles after the Curlew intersection and MAKE A U-TURN at Republic Dr./Hammock Pine Blvd. RIGHT TURN into Auctioneer driveway. Follow drive around to back — Suite #401
Take US 19 North. Go past Countryside Mall. The next light will be Republic Drive/Hammock Pines Blvd. Travel .25 miles north. TURN RIGHT into Auctioneer driveway after Bob’s Carpet Mart. (Look for the orange roof.) Follow drive around to back — Suite #401
Churney Periodontics Dental Service 28469 US 19 North Suite 401
Clearwater, FL 33761