Initial Health Form

Initial Health Form

To start your visit with us, please download the Initial Health Form and have it with you at your appointment. You can also fill out this information through the form below and submit it to us through the website.

Please have your insurance card and social security number with at the time of your visit.

  • INSURANCE INFORMATION

  • MEDICAL HEALTH INFORMATION

  • DENTAL INFORMATION

  • Please use your computer mouse to sign this section of the form.

    I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.