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(325) 949-1004

2121 Knickerbocker Road, Suite C.
San Angelo, TX 76904

Patient Forms

We know that your time is valuable. That’s why we offer a simplified office experience with online patient forms that you can complete prior to your appointment. You’ll spend less time in the waiting area, streamlining your initial visit. These forms help us better understand your background, allowing us to provide you with the most effective care possible. As always, please do not hesitate to contact us is you have any questions about patient forms or your appointment.

 

Patient Forms:

CLICK ON THE FORM NAME TO PRINT ALL THE PATIENT FORMS DESCRIBED BELOW:

PATIENT INFORMATION FORM – All new patients must complete this form.  Keep all of your contact and insurance information up-to-date with this form.  If you list an e-mail address, you can receive electronic appointment reminders and also confirm your visit with the click of a button!

         MEDICAL HISTORY FORM – This form is very important so that we may provide you with                         Optimal dental care.  List any current or past medical diagnosis’s, surgeries, medication allergies,               and medications you are currently taking.  Once completed, you only need to update this form as               changes arise, or every year.

PRIVACY PRACTICE ACKNOWLEDGEMENT – This notice describes how health information about you may be used and disclosed.  It also discusses your privacy rights as our patient and how you can get access to this information.  After your careful review, please sign the last page, acknowledging receipt of our practices.

FINANCIAL POLICY ACKNOWLEDGEMENT – This form details the expectations of our dentist / patient relationship.  Please ensure you read and understand all areas of this form, as you will be held accountable for its contents effective January 1, 2016.

INSURANCE DISCLAIMER – If you do not have DENTAL Insurance, you do not need to complete this form.  All others with dental insurance, please read thoroughly and sign indicating your acknowledement, as it details important insurance stipulations that may affect your benefits and out-of-pocket expenses.