Patient Forms / Registration

For New Patients, or Patients who we haven't seen in over 12 months:
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Please click on the buttons below to open each document. Print out and complete all three forms, and bring them to your appointment:
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Patient Registration Form

Health History Form

For the document below, please print and read all pages, but you may bring in only the last page with your signature on the day of your appointment. 

Privacy Practices / HIPAA

Financial Policy

Payment is required at the time of service.

We accept check, cash, as well as credit and debit cards.

Interest free financing is available through Care Credit. For more information on payment plans, please visit www.CareCredit.com.

If you have dental insurance, we will gladly submit your claim on your behalf. An insurance policy is an agreement between you and your insurance carrier. We will provide estimates based on your coverage. No insurance pays 100% of all procedures. Estimated co-pay is due at the time of service.

Should you have any questions regarding your bill, please do not hesitate to call the office at (563) 583-1050.