New Patient Form

Are you a new patient? Save time on paperwork by filling out the forms below prior to your appointment. If you have any questions, please feel free to give us a call. We can’t wait to meet you!

ASSIGNMENT AND RELEASE

All insurance benefits, it any, otherwise payable to me for services rendered I understand that I am financially responsible for all charges whether or not paid by insurance I authorize the use of my signature on all insurance submissions.

The above named dentist may use my health care information and may disclose such information to the above named insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services This consent will end when my current treatment plan is completed or one year form the date signed below.

IN CASE OF EMERGENCY CONTACT (Specify someone who does not live in your household.)
Place a mark on “yes” or ”no” to indicate if you have had any of the following:
Place a mark on “yes” or no to indicate if you have had any of the following:
Women:

MEDICATIONS

ALLERGIES

Please wait...