Our intake form is available for download and printing below.  The form is in Adobe Acrobat (PDF) format.

New Patient Form 2019 (PDF, 6 pages) 306 KB

If you do not have the free Adobe Reader it is available for download here:

We realize that six pages of paperwork may seem like a lot to complete.  It is.  However, it is very important that we establish an accurate picture of your personal information and your medical and dental histories (Pages 1-4).  In addition, we like to share with our patients some ideas regarding dental insurance because of the number of questions that arise each day (Page 5).  We want to convey the office policy regarding late cancellations of appointments.  Lastly, we need to make our patients aware that we offer several methods to help patients pay for their dental care, which we realize can be costly (Page 6).

Page 1 – New Patient Information

  • Basic names, address, contact information
  •  Emergency contact
  •  Employment status and insurance information

Page 2 – Medical Information

  • Important statement about having an accurate history
  •  Please circle any conditions that you have or have had
  •  Any conditions not listed can be listed also
  •  Questions for female patients
  •  Notice of Privacy Practices

Page 3 – Medications and Allergies

  •  The top and bottom of this page will be completed by our staff and updated as changes occur
  •  List of physicians and specialists
  •  Medication list: a printed list can be attached

Page 4 – Dental History

  • A chance for you to answer some questions and to provide some insight to the care you’ve received in the past, current concerns and future hopes or goals

Page 5 – Dental Insurance and Our Office Perspective

  • Some important points that we want to share with our patients regarding dental insurance and how we will work with you to understand these aspects of your care
  •  Bottom must be signed

Page 6 – Payment and Broken Appointment Policies

  • Please read and sign the bottom

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