New Patient Forms

New Patient Registration

You have two options for submitting our new patient questionnaire: electronically or hand written. Please review the options below and decide which way you would prefer to fill out the forms. To begin the electronic registration you will be asked to type your child’s name and date of appointment. Please complete the following:

Patient Information

Patient Information

Appropriate Medical History

Appropriate Medical History

Electronically

Please allow yourself enough time to complete the form in a single sitting. If you start the form, and then leave, the system may require you to start over. Estimated available time is 30 minutes. There are several pages of questions, use the arrow key at the bottom of the page to advance. When complete, hit the SUBMIT button to send the information to our office. Your signature will be added to the form when you arrive at the office.

Electronic Questionnaire

Printed

If you prefer, you may print these forms so you can fill them out at home. Simply click on the forms below to open them, they will open in a format which will allow you to view and print them from your web browser. Please print the Patient Information form as well as the appropriate medical history. Use the Child Form for children under age 12; use the Teen Form for children 12 and older.

Permission for a person other than parent
or legal guardian to consent to dental health care.

If you as a parent/legal guardian will not accompany your child(ren) to the dentist office, please complete and send
with your child(ren) the form below to permit us to treat your child as scheduled.