New Patient Forms

Please correct the errors described below.

General Information

Add additional contact #

Employment/Schooling Information

Emergency Contacts

Add additional emergency contact person

Referral Info

Current Needs

Responsible Party

If the Responsible Party is NOT the patient, please fill out the following information.

Payment Information

The options for payment will be explained to you after treatment plans have been discussed. Payments may be made in cash, check, VISA, MasterCard, American Express, Discover, or we can arrange third party financing for you.

If you have dental insurance, please provide us with the appropriate information so we can submit claims electronically for prompt reimbursement. As a courtesy to you, we will fill out the necessary forms for your insurance so you are reimbursed directly. We will make every effort to help you maximize your benefits.

Appointments are scheduled to allow sufficient time to attend exclusively to your needs. For appointments which are not kept or cancellations with less than 48 hours notice, we reserve the right to charge cancellation fee.

Photography Authorization & Release

Medical History

If "Yes", please list medications:

Add prescription medication

Dental Health & Appearance

Notice of Privacy Acknowledgment

  • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly
  • Obtain payment from third-party payers.
  • Conduct normal healthcare operations such as quality assessments and physician certifications.

Patient Authorization

Your information will be encrypted.