New Patient Forms


You're in great hands

Thank you for choosing our office for your dental needs. The following forms are a part of your new patient exam. For a shorter time in the waiting room, please fill out the New Patient Form and bring them in before your visit.


Download Individual Forms



General patient information, including current dental insurance policy. Providing your social security number is optional, however, in order to verify your insurance policy it is sometimes necessary to use this as an identifying piece of information. 

Download Form →


Financial Agreement

This agreement outlines the patient's financial responsbility for services received at our office. Primary insurance, secondary insurance, non-insured patient fees, payment options are discussed in this form. 

Download Form →


Copy & Signature of Privacy Practice

The Notice of Privacy Practices states how we may use and/or disclose your health information. A signed copy of the Notice is requested, but you may refuse to sign this acknowledgement if you wish.

Download Copy Form →

Download Signature Form →


Medical History

General medical history, including current medications, allergies, and medical conditions. 

Download Form →


Dental History

This form inquires about your previous dental history and what treatment you hope to receive at our office. 

Download Form →


HIPAA Patient Consent & Email Authorization

The Health Insurance Portability and Accountability Act (HIPAA) of 2003 is designed to ensure that privileged patient information is kept safe and only shared with people that you authorize. 

The Email Authorization form serves to disclose the inherent risks of communicating personal health information via email. You have the right to not authorize email communication. 

Download HIPAA Patient Consent Form →

Download Email Authorization Form →