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FORMS

Permission slip for treatments for children, students, that are dropped off or drive themselves to our office without a legal guardian. If you need cannot be with your child during their dental visit, please fill out the Guardian Permission form and send it with them.

• Guardian Permission Form (pdf)

Amalgam Silver Fillings:

• Amalgam Silver Filling Disclosure FORM (pdf)

For more information regarding amalgam fillings, click here

Blue Cross Federal Plan Participants:

• Blue Cross Federal Plan Form (pdf)

NEW PATIENT FORMS

New patients, for your convenience we have placed our new patient forms on this website.

Please print all five forms below. Fill out the registration and history forms. Fill out the new patient survey so we understand your expectations and prior dental experiences. Read and then sign the privacy practices and policies documents. Then bring all five forms with you to your first visit.

• Patient Registration (pdf)
  (This is a two page document. For slower Internet connections, download page 1 and page 2 individually.)
  
  
• Medical History (pdf)
  
  
• New Patient Survey (pdf)
  (Tell us about your expectations and previous dental experiences.)
  
  
• Notice of Privacy Practices (pdf)
  
  
• Financial & Office Policies (pdf)

 

If you do not already have Adobe Acrobat PDF Reader installed on your computer,
please go to Adobe and download the Acrobat Reader before opening the documents listed above.