Patient Forms

Demographic Information and Medical History Form (For New Patients Only)

Please take a minute to fill out the patient information form before your first appointment. Once you hit the submit button it will be sent to us.

• Demographic Information and Medical History Form

Annual Medical Update Form (For Current Patients Only)

Please take a minute to print and fill out the patient information form before your next appointment:

• Annual Medical Update Form

HIPAA Form

Please complete this to acknowledge receipt of our HIPAA Privacy policy and to authorize the release of your medical information to other individuals that you designate.

• HIPAA Privacy Policy Form

Dental Insurance Form

Please fill out our Insurance form for your first visit or if you have new insurance.

• Dental Insurance Form

ACH Debit Form

Our office gives you the option to have payments automatically withdrawn from your checking account.

• ACH Debit Form

Credit Card Authorization Form

Our office gives you the option to have payments automatically charged to your credit card.

• Credit Card Authorization Form

No-No Foods List

Print out our list of foods we recommend you stay away from while wearing braces.

• No-No Foods List