New Patient Information Form

Barnes Dental

Please correct the errors described below.

Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely. If you have any questions or need assistance, please ask us we will be happy to help.

Patient Information (CONFIDENTIAL)

Responsible Party

Insurance Information

Add Additional Insurance

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 Medical History

Women Only

Patient Dental History

Authorization and Release

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.

Your information will be encrypted.

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