Reason for Visiting:	Please select your reason for visiting. Cosmetic Consultation Dental Exam and Cleaning Jaw and/or Facial Pain Consultation Other
Title:	None Ms Mr. Dr. Mrs. Master Miss
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Phone1: *	home work mobile
Phone2:	Not Applicable home work mobile fax company pager assistant call back car ISDN Telex radio primary TTY/TDD
Phone3:	Not Applicable home work mobile fax company pager assistant call back car ISDN Telex radio primary TTY/TDD
Best Time to Call is:	morning afternoon evening
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The following forms can be downloaded to your computer and printed at home. By filling out these forms ahead of time you will save significant time of your visit.

If you have any questions when filling out the form, please do the best you can, and our staff will assist you with your questions on the day of your appointment.

Financial Policy
	1_Financial_Policy.doc	21 KB
	1_Financial_Policy.pdf	44 KB
Personal Information Sheet
	3_Personal_Information_Sheet.pdf	18 KB
Patient Health and Dental History
	4_Patient_Health_and_Dental_History.doc	63 KB
	4_Patient_Health_and_Dental_History.pdf	15 KB
HIPAA Signature Page
	6_HIPAA_Signature_Page.doc	25 KB
	6_HIPAA_Signature_Page.pdf	9 KB