Patient Forms

Please print out these forms, fill them out, and bring them with you on your first visit.

We accept most Aetna, Cigna and Assurant PPO plans. We also provide access to financing with CareCredit, a healthcare credit card accepted at over 175,000 providers nationwide. With CareCredit, you can pay for treatments and procedures for you and your family right away and then make convenient monthly payments. Application is quick and easy. Click the button below to get started.

New Patient Medical History Form
(58477 – Information Form.pdf)

Financial Policy
(60092 – Financial Policy.pdf)

Notice of Privacy Practices
(46312 – Notice of Privacy Practices.pdf)

Acknowledgement of Receipt of Notice of Privacy Practices
(60160 – Acknowledgement of Receipt.pdf)

Authorization for Disclosure of Protected Health Information (No Cavity Club Permission – Social Media Disclosure)
(60162 – Authorization for Disclosure.pdf)