Forms

If you are a New Patient to the office, you can save time at your first appointment by filling in our forms online and then printing them out or email them to us. We ask that each new patient fill out the following forms: General Information, Medical History, Dental History, Consent to Use Health Information and Receipt of Privacy Practices. If you have a list of medications already prepared, please make a copy and send it with the other forms.

Please read and keep a copy of the Notice of Privacy Practices, this is for your information.

For Existing Patients, it is very important for your safety that we know any significant changes to your Medical History including new medications. Also, dental insurance policies change often and can effect your copayments. For this reason, we will periodically ask you to update these forms.

Request Appointment

General Information Questionnaire
Name, address, phone numbers, email, insurance information, etc.

Medical History Questionnaire
Existing and previous medical conditions, medications and known allergies.

Dental Questionnaire
Existing and previous dental conditions, self evaluation of current dental health.

Consent to Use Health Information and Receipt of Privacy Practices
Consent to use and disclose your protected health information to carry out treatment, file insurance, and consult with appropriate specialist on your behalf. Acknowledge receipt of the offices privacy practices regarding your personal information.

Notice of Privacy Practices
Describes our legal responsibilities regarding your personal information, how it might be used, and your rights as a patient.