New Patient Paperwork

  • Patient Acquaintance Form

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  • Birthdate:
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  • Marital Status
  • Sex:
  • Insurance Coverage:
  • Date of Birth of Insured:
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  • Medical History

  • Are you allergic to any drugs or medications? (Yes/No) If yes, please list
  • Do you have artificial joints such as knee or hip replacements? If yes, please list with date:
  • Surgey Date
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  • High blood pressure? (Yes/No) If yes, please list medication:
  • A heart ailment, including mitral valve prolapse or heart murmur? (Yes/No)
  • Do you have a history of heart surgery? (Yes/No) If yes, please list:
  • Do you have Diabetes?  Do you have Rheumatic fever?  Do you have HIV or AIDS? If yes, please list medication:
  • Have you ever had any radiation treatment? Do you have epilepsy, convulsions, or seizures?  Do you have any pain in or near your ears? Check all that apply.

  • Dental History

  • Do you have or have you ever had any of the following: Click all that apply
  • Do you have or have you ever had any of the following: Click all that apply
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  • Unless prior arrangements have been made, payment is expected at time of service. In order to provide the best possible service, please notify us at least 24 hours in advance if you are not able to keep an appointment. Broken appointments will be subjected to a charge.

    I certify that the above information is true and accurate to the best of my knowledge. I accept full financial responsibility for my account, including any fees which are assessed to my account to collect any outstanding balance.

  • Date
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  • COVID-19 PANDEMIC - PATIENT DISCLOSURES

  • This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID-19 virus.

    A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID- 19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us.

    It is also important that you disclose to this office any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.

  • Do you have a fever or above normal temperature?*
  • Have you experienced shortness of breath or had trouble breathing?*
  • Have you recenly lost or had a reduction in you sense of smell?*
  • Have you been in contact with someone who has tested positive for COVID-19?*
  • Have you tested positive for COVID-19?*
  • Have you been tested for COVID-19 and are awaiting results?*
  • Have you traveled outside the United States by air or cruise ship in the past 14 days?*

  • I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system. By signing this document, acknowledge that the answers have provided above are true and accurate

  • Date
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  • Acknowledgement of receipt of notice of privacy practices

    *You may refuse to sign this acknowledgement*

  • I have received a copy of this office’s Notice of Privacy Practices.
  • Date
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  • Authorization to release specific protected health information

    *Per your request we are allowed to fax dental excuses to your school or business*

  • Date
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  • For office use only

    We attempted to obtain acknowledgement of receipt of our notice of privacy practices, but acknowledgement can not be obtained because

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