Forms & Office Policies
Combined Consent Form
When you come to the office the first time, you will be asked to sign a form indicating
- Have received a copy of the office privacy (HIPAA) policies;
- Agree to the office financial policy; and
- Give your consent for diagnosis and treatment.
You can review this form by clicking on the button below. The form
will open in a new window.
View/Print the Consent Form (PDF)
Patient Information/Medical History Form
Upon your first visit to our office, you will also be asked to complete a medical history form.
Due to the length and level of detail in this form, we strongly recommend that you complete
the form at home and bring it with you to your appointment. You can do this in two different
- Click the button to open the PDF file, print the form, and complete it by hand; or
- Click the button to open the file and try clicking in the first field of the form.
If you see a blinking cursor, you can complete the form on screen, then save it and
print a copy.
Please remember to bring the completed form and list of medications with you to your first appointment.
View/Print the Medical History Form (PDF)
The fee for your treatment will be presented at your first visit and
is due in full upon completion unless specific insurances
are involved. For your information and planning, a statement will be provided upon
your first visit.
We will provide information for pre-authorization
We will be happy to complete any insurance forms. However, you are
responsible for payment unless otherwise directed by the insurance company.
Special financial arrangements must be approved by the Office Manager.
When appointments are broken, full remittance is expected before completion of
We respect your right to privacy as it relates to your treatment and personal information.
We also acknowledge our legal obligation to keep private any health information that
identifies you. As part of that obligation, we are required to provide you with formal notice of
our privacy practices. Click on the
button below to review how we protect your health information and your rights regarding the
use of your personal information. The document will open in a new window.
View/Print Our Privacy Practices (PDF)
For Referring Dentists
Click the button below to access our patient referral slip. Fill out the slip (either by hand
or on your computer) and give it to the patient to bring to her/his appointment. Please point
out the patient instructions at the bottom of the form.
Thank you for the referral!
View/Print our Patient Referral Form (PDF)