New Patient Form

New Patient Form 2022

Patient Information

Street Name
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Include area code
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May we confirm your appointments by text?
Street Name

Patient or Spouse Information

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Dental Insurance Information

Our office will do everything possible to help you understand and make the most of your dental insurance. We do accept insurance benefits as partial payment for treatment along with your payment of the estimated patient portion cost. You are responsible for all fees and changes for your account. Please be assured that our staff will do all we can to help you receive maximum reimbursement from your insurance company.

Dental History

Thank you for choosing us to meet your dental needs. Our commitment to quality dental care for you is equal to our commitment to customer service. Our staff is here to assist you in any way we can. Please let us know if you have any questions or concerns.

Medical Information

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Please CHECK any/all of the medical conditions you currently have or have had in the past:
Please CHECK any/all of the medical conditions you currently have or have had in the past:

General Consent

Thank you for choosing our office for your dental care. We will work with you to help you achieve excellent oral health. While recognizing the benefits of a pleasing smile and teeth that function well, you should be aware that dental treatment, like treatment of any other part of the body, has some inherent risks. These are seldom great enough to offset the benefits of treatment, but should be considered when making treatment decisions.
Benefits of dental treatment can include: relief of pain, the ability to chew properly, and the confidence and social interaction that a pleasing smile can bring. Nonetheless, there are some common risks associated with virtually all dental procedures, including:

• Drug or chemical reaction. Dental materials may trigger allergic or sensitivity reactions.

• Long-term numbness (paresthesia). Local anesthetic, or its administration, while almost always adequate to allow comfortable care, can result in transient, or in rare cases, permanent numbness.

• Muscle or joint tenderness. Holding one’s mouth open can result in muscle or jaw joint tenderness, or in a predisposed patient, precipitate in a TMJ disorder.

• Sensitivity in teeth or gums, infection or bleeding.

• Swallowing or inhaling small objects.

While we follow procedural guidelines that most often lead to a clinical success, just like any other pursuit in health care, not everything turns out the way it is planned. We will do our best to insure that it does. Please feel free to ask questions in regard to all dental procedures that are recommended to you.

Missed Appointment Policy

Unforeseen events sometimes cause missing an appointment. If you need to cancel or reschedule an appointment, we respectfully request notification at least 24 hours prior to your appointment. Lack of sufficient notification may result in a Missed Appointment Fee being charged to your account.

Financial Policy

We strongly believe that all patients deserve the finest dental care that we can provide. You benefit from the high standards we have set for ourselves to deliver the utmost quality of dental treatment available. Accordingly, we have prepared this information to advise you of our financial policy.


For your convenience, our office offers the following methods of payment:

  • Cash
  • Check
  • Visa
  • Master Card
  • Discover
  • American Express

For extended payment options, our office offers:
Care Credit - Up to 12 months interest free: application required
Applications available at our office, online at or by phone at 1-800-365-8295


NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in my medical status. I will not hold the dentist or dental staff responsible for any errors or omissions that I may have made in the completion of this form.


I have read and understand the statements on this page.