Patient Forms

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You may access the following forms to assist us with your care. Please print and fill out the following forms, then bring them to your appointment. You also have the option of filling out the submittable form below the printable ones, we'll receive them via email. See you soon!

Printable Form

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*These forms require Adobe Acrobat Reader to view. If you do not have Adobe Acrobat Reader already installed on your computer, click the Adobe logo above to download.


Submittable Form

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Patient Information

Parent/Guardian Information

Emergency Contact

Insurance Information

Dental History

Medical History

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.

OFFICE USE ONLY

I have verbally reviewed the medical/dental information above with the parent/guardian and patient named herein.