New Patient Forms

Please fill out and submit the form, or download the form so you can print and fill it in later by hand.

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Patient Information

Relationship Status: for years.





Responsible Party
Insurance Information








Secondary Insurance Information







Dental History


Have you had any of the following problems? (check all that apply)













Medical History
  1. Have you ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of Lonimin, Adipex, Fastin (brand names of Phentermine), Pondimin (Fenfluramine) and Redux (Dexfenfluramine).
  2. Have you ever had any serious illnesses or operations?
  3. Have you ever had a blood transfusion?
  4. (Women) Are you pregnant? Are you nursing ? Are you taking birth control pills?
  5. Have you ever had any of the following? (check all that apply)





















































I certify that I, and/or my dependent(s), have insurance coverage with (Name of Insurance Company(ies)) and assign directly to Dr. all insurance benefits. If 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 the current treatment plan is completed or one year from the date signed below. To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.




Payment is due in full at time of treatment unless prior arrangements have been approved

Smile Analysis

Please check any statement you agree with:

















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