New Patient Forms

form If you would like to complete your registration form before you arrive, you may download it by clicking below. The new patient form is in PDF format. If you do not have Acrobat Reader, get a free copy by clicking on the link below. Also, after reading the Notice of Privacy Practices, print the Acknowledgement form below, sign it, and bring it in, too.

Patient Registration Form (Adult) (Acrobat PDF form)

Medical History (Adult) (Acrobat PDF form)

Dental History (Adult) (Acrobat PDF form)

Patient Registration Form (Child) (Acrobat PDF form)

Dental and Medical History (Child) (Acrobat PDF form)

Assignment of Benefits Form (Acrobat PDF form)

Notice of Privacy Practices (web page)

Acknowledgement of Receipt of Notice of Privacy Practices (web page)

© Copyright 2006- Dental WebSmith, Inc. and Kopczyk and Vieth, LLP. All rights reserved worldwide. Disclaimer: The information provided within is intended to help you better understand dental conditions and procedures. It is not meant to serve as delivery of medical or dental care. If you have specific questions or concerns, contact your health care provider.