Patient Forms

Please take a minute to print and fill out the patient information form before your first appointment:

• Online Patient Form (Child)
• Online Patient Form (Adult)
• Patient Form - Word Format
• Patient Form - PDF Format
• Patient Form (Spanish) - Word Format
• HIPPA Disclosure Form
• HIPPA Photography Release Form
• HIPPA Notice of Privacy Practice Form
• VIRTUAL TELEHEALTH CONSULTATION SERVICES FORM
• Dental Insurance Carrier Form
• Financial Policy & Agreement Consent Form
• COVID19 Disclosure Clearance Checklist Form
• COVID19 Emergency Dental Treatment Form
• COVID19 Dental Treatment Acknowledgement of Risk Form
• Refusal of Treatment Form
• General Dentistry Informed Consent Form
• General Dentistry Informed Consent for a Minor Form
• Pit and Fissure Sealants Informed Consent Form
• Periodontal Scaling and Root Planning Informed Consent Form
• In-Office Whitening Informed Consent Form
• Occlusal Nightguard Informed Consent Form
• Sports Mouthguard Informed Consent Form
• Stainless Steel Crown Informed Consent Form
• Pulpotomy Informed Consent Form
• Crown and Bridge Infromed Consent Form
• Full and Partial Denture Informed Consent Form
• Tooth Extraction Informed Consent Form
• Fremectomy Informed Consent Form
• Orthodontic Treatment Informed Consent Form
• Orthodontic Treatment for a Minor Informed Consent Form
• Sleep Apnea Appliance Informed Consent Form
• Pregnant Patient Education Informed Consent Form
• Blood Thinners Patient Education Informed Consent Form
• Medical Consult Clearance Informed Consent Form

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