Dentist Plymouth Appointment Request

New Patients  Please print and fill out a health history and a HIPAA form for each new person

 

Current Patients  To update your records just print and fill out the appropriate health form (unless we have requested a HIPAA form)

 

HEALTH HISTORY - ADULT

 

HEALTH HISTORY - CHILD

 

HIPAA CONSENT

 

FINANCIAL POLICY

 

HEALTHY SMILES PLAN

 

NOTICE OF PRIVACY PRACTICES

 

 

 

 

 

 

 

Patient Information (* denotes fields that are required)
Patient Name*
Phone Number*
Email Address
Are you a current patient?
No Yes
Best time(s) to call?
Morning Noon Afternoon Evening
Appointment Information
Preferred Appt Date
Preferred Appt Time
Message
Describe the nature of your appointment or any other comments