Below please find our new patient forms. You can fill these forms out electronically saving each one individually and then attach them in an email to our office at firstname.lastname@example.org. Another option would be if you would like to print the forms, complete them manually and turn them into our office during your initial consultation.
Anthem Periodontics and Dental Implants live secure patient forms
The box below is a secure version of our welcome package with legal signature boxes and all of the information we will need in order to begin your initial consultation. If you are comfortable filling out this secure document here online it will be confirmed by you at the email address you enter and then sent directly to our office. Please begin to fill out the form here by looking for the green START arrow making sure to complete as many of the fields as possible and not skipping the boxes outlined in red. Once all fields have been completed please click on the Esign button. Below this blue box, the same online form is available for download. You can also download the entire package to your computer to complete, print, and then bring it into our office.
Download Forms For Manual Completion:
If you are not comfortable submitting an online form such as the one above and you prefer to download this online form. Please find the download below. With this download you can either print this out and manually complete it, sign it and bring it into our office or you can type in all of the fields, then print it out, sign it and bring it into our office. PLEASE NOTE:
Unless you have the computer program Adobe Acrobat professional, you can NOT save the form after you have typed out the answers using this method.
Below Please Find A Description For Each Individual Page In Our Welcome Package:
Please feel free to open the packet, print the packet and fill it out. Thank you for taking your time to complete our forms, we have worked hard to ensure they are simple and easy to fill out.
Anthem Periodontics and Dental Implants Welcome Packet
Page 1: This is our basic get to know you page. We ask relevant questions pertaining to how to contact you, emergency contacts, basic medical information, and if relevant, insurance information.
Page 2: Acknowledgement of Receipt of Privacy Practices; This form asks for your signature to ensure that you have read and reviewed our Privacy Practices Information in the form above.
Page 3: Medical History; This form goes further into your medical history in order for us to better know you and any concerns we should have for your overall health and safety.
Page 4: Financial Acknowledgement; This form is your acknowledgement for financial responsibility.
Page 5: Privacy Practices; This form does not need to be filled out or signed, it is simply for you to review Our Privacy Practices.
Page 6: Website & Social Media Release Form. This form grants Anthem Periodontics permission to your images for our website, promotional materials, & social media.