Patient Information & Medical Health History

Please correct the errors described below.

Patient Information

Welcome to our Office! To assist us in serving you, please complete the following confidential forms. The information provided is important to your dental health.

Billing, Credit & Insurance Information

Medical Health History

Dental History

Authorization and Release

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my dentist of any changes to my health.

This consent will end when the treatment plan is completed or three years from the date signed below.

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

Your message will be encrypted.