Patient Forms 2017-05-17T18:26:00+00:00

Patient Forms

To help expedite your initial consultation, you can print out the two forms in the links below OR complete the online form below to avoid delays in the waiting room. PLEASE NOTE: this form submission is encrypted and has the necessary protections for your personal information.

NEW PATIENT FORM

HIPPA FORM


MaleFemale

Our office sends reminders for scheduled appointments, please check below for your consent:

Automated Phone Call
Text Reminder
Email Reminder

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Primary Dental Insurance Information

Secondary Dental Insurance Information


YesNo

YesNo



MouthNose

YesNo



YesNo

YesNo

YesNo


Abnormal BleedingAnemiaAsthmaBlood TransfusionCancerSinus ProblemsHeart SurgeryHemophiliaHIV/AIDSHeart MurmurShinglesUlcers/ColitisHigh/Low Blood PressureHepatitisKidney ProblemsRheumatic FeverSevere HeadachesFrequent Headaches
To the best of my knowledge, the information that I have given is correct and I understand that it is my responsibility to notify the staff of Dr. Holmes of any changes to my medical status. I also understand that the information given will be held in the strictest of confidence.
I authorize the dental staff of Dr. Holmes to perform the necessary dental services I/my child may need.
I understand that I am responsible for any co-payment, deductibles, or payments for services rendered that are not covered by my insurance.
I understand that upon the time of my office visit, I will be required to confirm the acknowledgements above with my physical signature.