Patient Forms


If you are a new patient to our office, the attached file contains our new patient bundle with forms that will need to be filled out when you arrive at our office. Printing them, filling them out and bringing them with you will allow us to attend to your dental needs more quickly than completing them on your arrival.  Thank you and please call our office at (757)599-8393 if you have any questions at all.

Patient Forms (Print & Complete All Forms Prior To First Office Visit)

 There are two types of appointments you could be scheduled for.  Your initial appointment could consist of a consultation explaining your diagnosis and treatment options.  If your dentist has referred you for a non-surgical root canal therapy, your appointment will consist of a consultation and treatment at the same appointment.

Please assist us by providing the following information at the time of your appointment:

  • Your referral slip and any x-rays if applicable
  • A list of all medications you are presently taking.
  • A list of all surgeries.

Please alert the office when scheduling your appointment if you have a medical condition that may be of concern: artificial heart valves and joints, rheumatic fever, etc. or if you are on any medication: heart medications, aspirin, anticoagulant therapy, etc. or require medication prior to dental cleanings: antibiotics, for premed.

A parent or legal guardian must accompany all patients under the age of 18 at both consultation and treatment appointments.



Each patient is financially responsible for his or her own account. WE CURRENTLY PARTICIPATE WITH ANTHEM BLUE CROSS & BLUE SHIELD, CIGNA, DECARE, DENTEMAX, DELTA DENTAL, DELTA CARE, GUARDIAN and CARECREDIT. We do not participate with any other insurance company.  Your insurance is a contract between you, your employer and the insurance company.  We will gladly file all insurance claims for you.

Prior to your appointment, we have found out what coverage your insurance offers. Regardless of insurance status at the time, you are ultimately responsible for the balance of your account, which the insurance company does not cover.

For your convenience we accept cash, check, CareCredit, Visa, MasterCard, American Express and Discover.  Payment is due at the time that services are rendered. 


 This web site uses files in Adobe Acrobat Portable Document Format  (pdf) which require Adobe® Acrobat® Reader for viewing and printing. It is available to download free.