Patient Forms

Filling out your medical forms can be a hassle for anyone, and to make it convenient for our patients, we offer ‘fillable’ forms that are linked below. You may please consider filling these at your leisure, in the privacy of your home, and bring with you as a printout, or email back to us.

Here is a brief explanation of the forms you will find by clicking the link:

Medical History: Basic Medical History to better assess your overall health and consider any potential interactions with dental treatment.

General Consent and Information: Basic general consent to possible risks, complications, of dental procedures, and an explanation of how dental treatment, just like medical treatment, is always a fluid treatment plan that can sometimes require reconsideration of the proposed therapy to ensure the best prognosis and outcome for the patient. No treatment is ever done without full explanation of risks, benefits and alternatives to the proposed treatment, and with full verbal and written consent of our patients.

Notice of Privacy Practices: This form delineates how we share your information, on the rare occasion that it is required, such as by insurance companies, or mandated federal authorities, upon audit.

Acknowledgement of “Notice of Privacy Practices”: This form is an acknowledgement that you have received the notice mentioned above.

Photo Consent: Basic photography consent that lets the doctor take individualized, clear, intra and extra oral (inside and outside the mouth) pictures, to better diagnose and explain the situation to our patients.

Dental Materials Fact Sheet

Acknowledgement of Dental Materials Fact Sheet: This form is an acknowledgement of a fact sheet which can and will be provided to you upon request, and it indicates the technical differences between the different types of materials that are used in routine dentistry, such as silver, mercury, composite, etc.

Insurance Information: Basic Insurance Information, so we can create a breakdown of your coverages and explain your treatment options to you. This form is an in office form and usually does not need your attention unless we have devised a custom treatment plan for your particular needs.

Treatment Plan / Financial Options: This form delineates the proposed treatment for that particular day, indicating clearly, what charges are to be applied, including insurance, copayment, etc. This form is not to be signed until you present to our office and are explained the proposed treatment and financials for that day.