Patient Forms
Preparing for Your Appointment
We want to make your visit as smooth as possible. To ensure efficient care, all new and existing patients must complete the necessary paperwork before their appointment. These forms help streamline your visit and maximize your benefits.
We’re going digital! Downloadable forms available now – soon you'll be able to fill them out online and email them back with ease.
New Patient Forms:
1. PATIENT REGISTRATION
2. MEDICAL HISTORY
3. DENTAL INFORMATION
4. FINANICAL AGREEMENT
5. NOTICE OF PRIVACY PRACTICES
6. RECORDS RELEASE
Existing Patient Forms to Update:
1. PATIENT REGISTRATION
2. MEDICAL HISTORY
3. FINANICAL AGREEMENT
4. NOTICE OF PRIVACY PRACTICES
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How to Complete Required Forms:
✔ Download, complete, and email your forms to us.
✔ Request a mailed copy if preferred.
✔ Fill them out in our office—please arrive 15–20 minutes early and let us know in advance.
If you have any questions about your treatment, insurance, or financial responsibility, our team is happy to assist you. While we work to maximize your benefits, any balance not covered by insurance is the patient’s responsibility.
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1. Patient Registration
[Download Form]
This form collects essential information, including:
- Personal Details – Name, contact info, date of birth
- Emergency Contact – Name, relationship, phone number
- Insurance Information – Provider, policy number, subscriber details
Why It’s Needed:
✅ Keeps records up to date
✅ Prepares for emergencies
✅ Verifies insurance details
✅ Supports treatment planning
2. Medical History
[Download Form]
This form ensures safe and effective treatment by gathering details on:
- Medical Conditions – Chronic illnesses, past surgeries, ongoing treatments
- Medications & Allergies – Current prescriptions and known allergies
- Dental History – Past procedures, concerns, or sensitivities
Why It’s Needed:
✅ Prevents complications from health conditions or medications
✅ Alerts the dental team to allergies or risks
✅ Ensures personalized care
3. Dental Questionnaire
[Download Form]
This form helps us understand your oral health history, including:
- Gum Health – History of periodontal issues
- Oral Hygiene Habits – Brushing and flossing routine
- Smile Satisfaction – Any cosmetic concerns
- Oral Health Issues – Sensitivity, pain, or past dental procedures
Why It’s Needed:
✅ Detects early signs of dental issues
✅ Tailors preventive care recommendations
✅ Supports personalized treatment planning
4. Financial Policy
[Download Form]
Understanding our financial policies helps ensure a smooth experience. This form explains:
- Patient Financial Responsibility – Patients are responsible for all costs not covered by insurance.
- Insurance Billing as a Courtesy – We submit claims, but coverage is not guaranteed.
- Payment Expectations – Payment is due at the time of service unless arrangements are made.
- Appointment & Cancellation Policies – Guidelines for missed appointments and rescheduling.
Why It’s Important:
✅ Prevents billing confusion
✅ Encourages patients to understand their insurance coverage
✅ Ensures transparency and accountability
We bill insurance as a courtesy, but any remaining balance is the patient’s responsibility.
5. Privacy Policy
[Download Form]
We are legally required to protect your personal information under HIPAA regulations. This policy explains:
- How your data is collected and used
- Your rights to access and manage your records
- How we protect your information
Why It’s Important:
✅ Ensures patient confidentiality
✅ Meets legal compliance requirements
✅ Builds trust and transparency
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6. Records Release
[Download Form]
This form allows us to request your previous dental records from your prior dentist. Having these records helps us provide the best care and ensures a smoother insurance process.
Why It’s Needed:
✅ Tracks Dental History
✅ Prevents Insurance Limitations
✅ Ensures Insurance Coverage – Many insurance companies require exact dates of past crowns, fillings, and cleanings before approving new treatment—even if they did not pay for the original procedure.
Providing this information helps prevent unexpected insurance denials and ensures you receive the maximum benefits available under your plan.
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Need Help?
If you have any questions, feel free to contact us. We look forward to welcoming you!