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Please fill out this online form prior to your appointment. You can also print a copy and bring it along to your appointment if you prefer. 

Incase of emergency who should we contact?

Dental History

Please check below if you have any dental concerns:

Medical History

Have you ever had or do you suffer from any of the below?

I, the undersigned, hereby authorize the doctor to take radiographs, study models, photographs or any other diagnostic aids he deems appropriate to make a thorough diagnosis of my dental need. I also authorize the doctor to perform any and all forms of treatment, medication and therapy that may be indicated. I authorize and consent that the doctor employ any such assistance as he deems appropriate.

I understand that I am personally responsible for payment of all fees for dental services provided in this office for me or my dependents, regardless of insurance coverage. Breach of this responsibility carries the penalty of compensating the practice for any related attorney's and collection fees. I understand that payment is due when services are rendered.

Thank you! We look forward to seeing you soon!

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