Patient Forms

New Patient Form

• Open formto fill out all new patient forms.

It takes about four minutes to fill out.
For more information about how to fill out each form, see below:

Annual Forms

• Open formfor Forms #2, #5, and #7— Annual Forms

These 3 forms are our normal annual forms that need to be filled out, see below for details about each form. Remember to click "Next" after each form and "Submit" when done with the 3rd form. Use your finger, mouse, or stylus to sign the forms.

Update Forms (for existing patients)

• Open form for #1 — Patient Form
• Open formfor #2 — Medical History Form
• Open formfor #3 — HIPAA Form
• Open formfor #4 — Assignment of Benefits Form
• Open formfor #5 — Consent to Proceed & Financial Consent Form
• Open formfor #6 — Records Release Form
• Open formfor #7 — Materials Choice Form

For more information about how to fill out each form, see below:

#1 – Patient Form – This is basic information about you. Remember, ALL information you input is ENCRYPTED and safe as it is sent to our office. We need social security number and birth date to process dental insurance claims and if patients need payment plans, etc.

#2 – Medical History Form – This tells us about medications you are taking, allergies you have, and illnesses you have had or currently have. This information is important to help us provide the best care possible. Please sign the bottom of the form with your finger or stylus.

#3 – HIPAA Form – We have included a copy of the HIPAA: Notice of Privacy Practices below as it is referenced in this form. Feel free to read it below if you would like, before signing that form (English and Spanish version included). Please sign the bottom of the form with your finger or stylus. View notice to view the Notice of Privacy Practices.

#4 – Assignment of Benefits Form – We process all claims as a courtesy to our patients. Patients are only charged their estimated co-pay at the time of the service, as determined by their specific insurance company. There are few times where the insurance company will mail the patient the amount for the dental work that was performed instead of to our office. Please sign the bottom of the form with your finger or stylus.

#5 – Consent to Proceed & Financial Consent Form – This is a consent form to allow dental services to be rendered, and also our financial consent form. Please sign the bottom of the form with your finger or stylus.

#6 – Records Release Form – On this form, you only need to input names of anyone you would like to have access to your dental care information. You can leave this page blank if there isn’t anyone you want to have access to this information. Please sign the bottom of the form with your finger or stylus.

#7 – Material Choice Form – We enjoy giving our patients the option to upgrade to better materials when they are available, and you are NEVER required to choose an upgrade. By signing this form, you allow our office to offer you choices between different materials and explain any differences in cost and quality. You can then choose which material you would like for us to use.