New Dental Patient Forms

Convenient Forms

Make your dentist appointment even faster by using our printable new patient forms. We hope providing these forms ahead of time makes your visit even more convenient for you. At your appointment, our office will ask you to provide patient registration details such as name and address, responsible party, consent for treatment, etc. You can save time by printing and filling out these forms yourself. After you’ve completed them, simply bring them with you to your appointment. Although it’s not required, bringing completed forms saves both time and and effort.

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Download Forms

  • New Patient Form
  • Agreement to Pay for Treatment
  • Dental History Form
  • Medical History Form

Please note, if you would like us to coordinate with another dental clinic to request x-rays, please complete this form:

  • X-Ray Release Form
  • HIPAA Authorization Form

Note: To download Adobe Acrobat Reader for free, click here

Contact Us

If you have any questions or concerns regarding your dental care, our dental services, dental appointment or treatment, contact us today.

Phone: (434) 385-8888

Address: 3700 Old Forest Rd, Lynchburg, VA 24501

Map: