New Patient Medical & Dental Form

    Dental Information
    If YES, would you consider our custom Boutique Whitening treatment.
    Medical Information
    Insurance (Optional)
    Consent and Privacy Policy
    Any information is collected and maintained in accordance with State and Federal Privacy Legislation. A copy of our privacy policy can be obtained online at Privacy Policy. I have accurately completed this medical history form to the best of my knowledge. I understand that the nature, implications, and risks of the proposed treatment plan have been explained to me and I consent to receive dental treatment required to be carried out by the dentists and their staff. I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service unless other arrangements have been made. Failure to attend an appointment without giving adequate notification will incur a broken appointment fee which is required to be paid before we can provide you with further appointments. I authorise my dentist to take videos and images of my before and after dental treatment. I understand these videos / images may be used in a practice portfolio/social media to showcase examples of dental work to others.

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