Patient Information Form


Please correct the errors described below.

We warmly welcome you to our office. Please take a few moments to complete the following information so that we can better care for you. It is our goal to help you reach and maintain maximum oral health

In the event of an emergency, whom should we contact?

Dental Insurance

Secondary Dental Insurance


A note for patients with dental insurance – We will assist you to maximize your insurance benefits, and we are happy to file claims to your insurance carrier and agree to accept payment from any carrier that offers an assignment of benefits, if you desire. We will do our best to calculate your available benefit amount, however, regardless of what your insurance plan pays, you are responsible for all fees.

Medical History

Are you allergic to any of the following items?

Dental History

HIPPA Compliance Statement:
Your health information may be used in our office to conduct scheduling and coordination of care between the doctor, dental assistant, hygienist, business staff and other health care providers. We may include your health information (including x-rays) with communications related to your treatment and we may do this with insurance forms filed via mail or electronically. We may communicate with you via phone, messages, postcards/letters, or electronically.

I understand that this information is correct to the best of my knowledge. I understand it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status.

I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent. I give permission for the doctor or their staff to use any photos taken for lecturing, publishing, educational, or promotional purposes.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient portion is due in full at the time of treatment

Your information will be encrypted.