Patient Form

By clicking the submit button below, I certify that I have provided an accurate and complete personal and medical/dental history to the best of my knowledge. All information is confidential and is accessed only via a secure, encrypted interface. Should there be any change in my personal or health status in the future, I will advise this dental office. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another health care provider may be necessary. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services. I understand that 48 hours notice is required for changing or cancellation of my appointments, otherwise there is $70 charge per hour that may be applied.