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Patient Forms

We're excited to meet you! Please take a few minutes to fill out our New Patient Form.  You can fill out the online form to the right, or you can click here to download a PDF of our forms.

 

If you have any questions, we're happy to help you! Just contact our office.


Please note that this form does time out after 20 minutes, please complete in one sitting.
* Required

New Patient Information



























Responsible party













Secondary Insurance











Patient Information










Bad Breath
Bleeding Gums
Clicking or poping jaw
Food collection between teeth
Grinding teeth
Loose teeth or broken fillings
Periodontal treatment
Sensitivity to cold
Sensitivity to hot
Sensitivity to sweets
Sensitivity when biting
Sores or growths in your mouth


Medical History











AIDS
Anemia
Arthritis
Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Back Problems
Blood Disease
Cancer
Chemical Dependancy
Chemotherapy
Circulatory
Cortisone Treatment
Cough
Persistent
Cough Up Blood
Diabetes
Epilepsy
Fainting
Glaucoma
Headaches
Heart Murmur
Heart Problems
Hemophilia
Hepatitis
High Blood Pressure
HIV Positive
Jaw Pain
Kidney Disease
Liver Disease
Mitral Valve Problems
Nervous Problems
Pacemaker
Psychiatric Care
Radiation Treatment
Repiratory Disease
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Skin Rash
Swelling of Feet
Stroke
Thyroid Problem
Tobacco Habit
Tonsillitis
Tuberculosis
Ulcer
Venereal Disease


Authorization

I authorize my insurance company to pay the dentist all insurance benefits otherwise payable to me for services rendered.

I authorize the use of this signature on all insurance submissions.
 
I authorize the dentist to release all information necessary to secure the payment of insurance benefits.
 
I understand that i am financially responsible for all charges whether or not paid by insurance.