For your convenience our forms are in pdf form and you can print the full packet or each individual form.

Packet of all Forms (7 pages)

Separate Forms:

Welcome- Patient Information Form (p.1 of packet)
Questionnaire (p.2 of packet)
Medical History (p.3 of packet)
Notice of Privacy Practices (HIPAA) (p.4 & 5 of packet)
Acknowledgement Receipt (HIPAA) (p.6 of packet)
Appointment Policy (p.7 of packet)

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Appointment Policy

Your appointment time is reserved just for you. Our goal is to provide you with excellent, personalized,
dental care. We strive to exceed your expectations. Excellence does not just happen, it is planned.
Your appointment is chosen so we can give you priority attention, and the time necessary for performing
the detailed procedures with excellence. Your cooperation enables us to do this by:

  • Choose your appointment time thoughtfully to avoid conflicts of your time and make your appointment a priority.
  • If you have special needs regarding the selection of your appointment times please let us know so we can assist you.
  • Be on time to your appointment. Depending on the procedures planned, arriving late may necessitate rescheduling the appointment or modifying the treatment that can be performed in the remaining time.
  • Call us well in advance if it becomes necessary to change your appointment. Most of our patients give us at least one week’s notice.

We are sympathetic to an occasional emergency, as they are unplanned; however same day
cancellations or failing to come to your appointment is considered a broken appointment. A
broken appointment is a loss to all concerned.

  • Your treatment gets delayed, as our next opening may be many weeks later.
  • Another patient who would like to be seen sooner isn’t given enough notice.
  • The practice loses time and revenue
  • Our preparation for your appointment is wasted.

A pattern of broken appointments may lead to dismissal from the practice.