Dental Forms

In order to keep our patients and staff safe and healthy, now all the forms must be filled out online, prior to your appointment. Your appointment will be considered unconfirmed until you have filled out all the required forms.

Click on the forms below to be taken to a secure page to fill out each necessary form, prior to your appointment. Make sure that you hit “SUBMIT” when you are finished filling out all the forms. If you need assistance please contact our office.

If you are a new patient please click on the “New Patient Forms” to fill out ALL of the REQUIRED forms, for your appointment, in one link.

New Patient Forms

Cancellation Policy

There is a $50 charge for missed, canceled, or rescheduled preventative appointments (cleaning, exam, or consultation) with less than 24-hour notice.*

There is a $100 charge for missed, canceled, or rescheduled basic or major service appointments (fillings, root canals, crowns, deep cleanings, etc). with less than 24-hour notice.*

*Appointment restrictions may also be enforced.

You may cancel appointments by calling, emailing, or texting the office.

HIPAA Form

Read, review, and sign this form in order to receive dental treatment . This form must be signed at least once. If you are unsure whether or not you signed this form previously, just sign it.

Registration Form

Fill this form out if it has been 6 months or more since your last visit, if it is your first time in the office or if your information has changed since the last time you were in the office.

Medical Form

Fill this form out if this is your FIRST visit to the office.

Medical UPDATE Form

Fill this form if it has been 6 months or more since your last visit to the office or if you have changes in your medical history since your last visit.

Financial Agreement Form

Read, review, and sign this form in order to receive dental treatment . This form must be signed at least once. If you are unsure whether or not you signed this form previously, just sign it.

Dental Treatment Agreement Form

Read, review, and sign this form in order to receive dental treatment. This form MUST be signed at least once. If you are unsure whether or not you signed this form, previously, just sign it.

Cancellation Agreement Form

Please carefully read, review, and sign this form. It details our office policies in regards to tardiness, rescheduling, and cancellations. This form MUST be signed at least once. If you are unsure whether or not you signed this form, previously, just sign it.

Treatment of a Minor Without a Parent

If you are unable to attend your child’s appointment together with your child, please fill out and sign this form.

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