Health History Form
Please print this form, fill it out and bring it with you to your appointment.
Patient Acknowledgment and Consent Form
We also need you to fill out a Patient Acknowledgment and Consent Form. This form outlines our privacy practices about your patient information. You can print a copy of this form and bring it to your office with you for your appointment.
Dentist Referral Form
You may also have a referral form from your general dentist. Please bring that with you.
When you visit our office, please bring your insurance cards with you and be prepared to pay your co-pay at the time of service. If you’re unsure of your co-pay amount, please contact your insurance company before your appointment. We participate with Delta Dental and, while we don’t participate with other insurance companies, we’ll be happy to file a claim for you. To file an insurance claim for you we will need your social security number, so please be sure to include it when you fill out your Health History Form. If you don’t wish to provide us with your social security number, we do ask you for full payment at the time of service.
Thank you. We look forward to seeing you soon.
– John C. Hall, D.D.S., M.S.