Patient Forms

 
704-504-8070
The first step towards a beautiful, healthy smile is to schedule an appointment. Please contact our office by phone or complete the appointment request form below. Our scheduling coordinator will contact you to confirm your appointment.

Please do not use this form to cancel or change an existing appointment.

 

Please complete forms one and two, print these out and bring them with you to your first visit with us.  Please review form 3, the dental insurance policy.  Form 4 is for patients who are transferring their x-rays.  We look forward to meeting you soon!

1.  New Patient Registration.doc  (Medical History and Registration)

2. Release of Information.doc      (HIPPA form)

3.  Dental Insurance Policy.doc        (Our policy on dental insurances)

4.  Xray Release Form                      (Release form for patients who are transferring)

 
*Items in bold are required.
Are you a current patient?


Preferred day(s) of the week for an appointment?

Preferred time(s) for an appointment?

Please describe the nature of your appointment (e.g., consultation, check-up, etc.):

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.

Healthy Smiles

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