Dayton, OH
(937) 237-0360

Patient Forms

In order for us to spend more individual time with our new patients we ask that you download and print the new patient registration and medical evaluation form then complete the form, being sure to include your cell phone and email address. This will mean that during your appointment we can spend your valuable time discussing and evaluating your wants and needs for better oral health.

Dental History

Medical History

New Patient Registration

Prior to your visit to our office, you may click on the above patient forms to download the PDF file to your computer. After doing so, you may open the file on your computer, fill out the form and save the file again. You may then send our office an email with the newly saved PDF attached as a file. Please email our offices at, and we will have them included in your file at the time of your visit! Or, alternatively, you may print the forms and bring them with you to your next appointment.

Notice of Privacy Practices

SUMMARY: This government rule includes standards to protect the privacy of individually identifiable health information. The rules below, which apply to health plans, health care clearinghouses, and certain health care providers, present standards with respect to the rights of individuals who are the subjects of this information, procedures for the exercise of those rights, and the authorized and required uses and disclosures of this information. The use of these standards will improve the efficiency and effectiveness of public and private health programs and health care services by providing enhanced protections for individually identifiable health information. These protections will begin to address growing public concerns that advances in electronic technology and evolution in the health care industry are resulting, or may result, in a substantial erosion of the privacy surrounding individually identifiable health information maintained by health care providers, health plans and their administrative contractors. This rule implements the privacy requirements of the Administrative Simplification subtitle of the Health Insurance Portability and Accountability Act of 1996.