New Patient Form

Please give your insurance card to the receptionist

The following information is required to thoroughly diagnose any condition and give the highest possible standard of professional services. All information will be kept strictly confidential.

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. Should there be any change in either my health status or any other information I have provided, I will advise this dental office. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another health care provider may be necessary and I consent to release this information. I assume full responsibility for payment of dental services provided for myself and my dependants, and authorize release to my dental benefits plan administrator of information contained in claims submitted. This authorization shall continue in effect until the undersigned revokes the same.