Patient Forms

Please print and fill out these forms so we can expedite your first visit:

Dental History Health History Patient Registration General Consent Notice of Privacy Practices Cancellation Policy

Mission Statement

Our practice is working together to realize a shared vision of uncompromising excellence in dentistry.
To fulfill this mission, we are committed to:

  • Listening to those we are privileged to serve.
  • Earn the trust and respect of patients, profession and community.
  • Exceed your expectations.
  • Ensure a creative, challenging and compassionate professional environment.
  • Strive for continuous improvement at all levels.
Patient Rights
  • You have a right to choose your own dentist and schedule an appointment in a timely manner.
  • You have a right to know the education and training of your dentist and the dental care team.
  • You have a right to arrange to see the dentist every time you receive dental treatment, subject to any state law exceptions.
  • You have a right to adequate time to ask questions and receive answers regarding your dental condition and treatment plan for your care.
  • You have a right to know what the dental team feels is the optimal treatment plan as well as the right to ask for alternative treatment options.
  • You have a right to an explanation of the purpose, probably (short and long term) results, alternatives and risks involved before consenting to a proposed treatment plan.
  • You have a right to be informed of continuing health care needs.
  • You have a right to know in advance the expected cost of treatment.
  • You have a right to accept, defer or decline any part of your treatment recommendations.
  • You have a right to reasonable arrangements for dental care and emergency treatment.
  • You have a right to receive considerate, respectful and confidential treatment by your dentist and dental team.
  • You have a right to expect the dental team members to use appropriate infection and sterilization controls.
  • You have a right to inquire about the availability of processes to mediate disputes about your treatment.
(Adopted by the American Dental Association in 2009)
Your Responsibilities as a Patient
  • You have the responsibility to provide, to the best of your ability, accurate, honest and complete information about your medical history and current health status.
  • You have the responsibility to report changes in your medical status and provide feedback about your needs and expectations.
  • You have the responsibility to participate in your health care decisions and ask questions if you are uncertain about your dental treatment or plan.
  • You have the responsibility to inquire about your treatment options and acknowledge the benefits and limitations of any treatment that you choose.
  • You have the responsibility for consequences resulting from declining treatment or from not following the agreed upon treatment plan.
  • You have the responsibility to keep your scheduled appointments.
  • You have the responsibility to be available for treatment upon reasonable notice.
  • You have the responsibility to adhere to regular home oral health care recommendations.
  • You have the responsibility to assure that your financial obligations for health care received are fulfilled.
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