Click here to 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:
- Click here for 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.
- Click here for #1 — Patient Form
- Click here for #2 — Medical History Form
- Click here for #3 — HIPAA Form
- Click here for #4 — Assignment of Benefits Form
- Click here for #5 — Consent to Proceed & Financial Consent Form
- Click here for #6 — Records Release Form
- Click here for #7 — COVID Release 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. Please sign the bottom of the form with your finger or stylus. Click here 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 – COVID Release Form – Sign this Form acknowledging you understand there is a risk of acquiring the virus in an office like anywhere else, and that you don’t have symptoms at this time.