Welcome to our practice!

We are genuinely pleased that you have chosen us for your dental care. We are always excited to see new smiles coming through our door! In order to provide you with the best level of care, we need to get some information from you. Please fill out your new patient forms below, or plan to arrive 15 minutes early to your appointment to complete them in the office.

PATIENT REGISTRATION






Policy Holder
Responsible Party


Responsible Party (if someone other than the patient)
















Responsible Party is also a Policy Holder for Patient
Primary insurance Policy Holder
Secondary insurance Policy Holder


Patient Information






MaleFemale

SingleMarriedDivorcedSeparatedWidowed








I would like to receive correspondences via e-mail

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Part Time
Retired

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Part Time

Encore Launch Loyalty Discount PlanWord of Mouth
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Drive ByMedicaid







Primary Insurance Information



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Secondary Insurance Information



SelfSpouse
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MEDICAL HISTORY



Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may
have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the
following questions.


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Women Are you: ?


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Aspirin PenicillinCodeineLocal Anesthetics
AcrylicMetalLatexSulfa drugsOther

Do you have, or have you had, any of the following?

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CONSENT FOR USE AND DISCLOSURE
OF HEALTH INFORMATION

SECTION A: PATIENT GIVING CONSENT (PARENT OR GUARDIAN IF PATIENT IS A MINOR)






SECTION B: TO THE PATIENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

Purpose of Consent: By ​ signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of your Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:





Right To Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.