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Your First Dental Visit

As a new patient, make sure to give yourself about 1 hour for your appointment.  This is so we can provide you with the utmost care and time to understand any concerns you may have.  To save some time, you can fill out your new patient paper work in advance online.  We accept insurance and provide a membership option for individuals who do not have insurance.
 

New Patient Form

Insurance Information

Are you the Primary Insured Member?

Medical Health History

Check al that apply
Are you allergic to, or have you reacted adversey to any of the following?
For Women
Do you smoke, vape, or use tobacco?
You have the right to maintain your Protected Health information (PHI) as private. We will only share your information with corresponding parties deemed necessary by the dentist, such as your insurance company. Do you wish to have your PHI disclosed to other individuals (ex: Parents, Spouse, etc)?*

*I understand that I have a right to revoke this authorization at any time.  My revocation must be in writing.  I am aware that my revocation is not effective to the extent that the persons I have authorized to use and/or disclose my PHI have acted in reliance upon this authorization.

If Yes, please list a max of 2 individuals below that you release to receive your PHI, this includes being able to discuss your dental treatment.

Trusted PHI Person 1:

Trusted PHI Person 2:

Thanks for submitting!