Doctor of Dental Surgery

 Forms for Patients

The parent/guardian fills out this regarding themselves:

and fills out one of these for each child:

Government-required information:


  • the medical history form needs to be done every checkup

  • the other forms only need to be filled out once, unless there are changes

  • if the child has heart disease fill this out:  click

  • if you won't allow us to use fluoride to help prevent cavities, fill out this form:  click

  • these forms require using your typed name as your electronic signature.

  • instead, you may fill this form out in the office on our laptop and sign on a signature pad, but that will require arriving 10 minutes early for your appointment.