The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out this form completely. The better we communicate the better we can care for you.

About you, the patient:

Dental Insurance Info

Primary Dental Insurance

Secondary Dental Insurance (if applicable)

Employer Info:

Spouse Info:

Responsible Party

Dental History

Previous Dentist:

Medical History

For women:

To your knowledge, have you ever had any of the following medical conditions?(Select all that apply):

I realize that my insurance company, if any, has an obligation to me and not to the dentist. This office has no contractual arrangement with insurance carriers, therefore I am responsible to this office for payment of services rendered. I authorize this dental staff to perform any necessary dental services with my informed consent that I need during diagnosis and treatment.

Sign below to agree to the terms above and certify all information is correct: