New Patient Form

In an effort to serve you better, we would ask you to complete the following. We will be glad to assist you.
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In case of emergency, we should notify:

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any you do not understand. Please fill in the entire form.

Financial Information

ALL CHARGES YOU INCUR ARE YOUR RESPONSIBILITY REGARDLESS OF YOUR INSURANCE COVERAGE. If payment is not received or your claim is denied, you will be responsible for paying the full amount at that time.

PLEASE NOTE: If you have insurance it is important for you to inform us of any coverage changes, so that we can update any information before your next visit.

KINDLY BE ADVISED that as a courtesy to other patients and our staff, we require at least 2 business days notice to make any changes or cancel an appointment or a fee may apply. Thank you.

I, the undersigned, understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I have completed is correct and I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care services provider as is required by this dental office. I authorize this dental office to perform diagnostic procedures as may be required to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependents. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.

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