Patient Information (Confidential)

Dear Patient,

We would like to extend a very warm welcome to youo! We are genuinely pleased that you have chosen us for your dental care. Our practice realizes the importance of referrals and we value them greatly. We are always excited to see new smiles coming through our door!

First Name Last Name

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Area Code Phone Number

First Name Last Name

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

First Name Last Name

Self Spouse Child Other

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

First Name Last Name

Self Spouse Child Other

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Pregnant/Trying to get pregnant Nursing Taking oral contraceptives

Aspirin Penicillin Codeine Acrylic Metal Latex Sulfa Drugs Local Anesthetics

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

Thank you for you continued trust in our practice. As with the transmission of any communicable diseases like the cold or flu, you may be exposed to COVID-19 (Coronavirus) at any time or any place. Rest assured that we have always followed the infection control policies as stated by the state and federal regulations. We use universal precautions and the proper PPE to limit the transmissions of all diseases in our office and will continue to do so.

Despite our careful attention to sterilization, disinfection, and the use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurant. Social Distancing nationwide has reduced the transmission of the Coronavirus.

Although we have taken measures to provide social distancing in our practice due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, dental assistants and hygienist and sometimes other patients at all times. Exposure to the virus is very unlikely.

Patient Information (Confidential)

Responsible Party

Primary Insurance Information

Secondary Insurance Information

Medical History

Medical History

Patient Screening Form

COVID-19 Informed Consent Form