Thank you for choosing our office to meet your dental needs! We look forward to meet you at your upcoming appointment to prove you that you made a great choice.

We understand that for many patients the experience of coming to the dentist can make people feel anxious or nervous. We understand your concerns and it is our goal to make you feel comfortable and relaxed. To help you feel at home we offer headsets and wide selection of musical tastes through iHeart Radio. Please do not hesitate to bring your own selection of musics if it makes you even more comfortable. For dental treatment we have the ability of sedating our patients.

In your first visit you can expect to receive a full comprehensive evaluation from Dr. Petri, and any necessary X-rays. We like to schedule the first visit to last about 60 minutes to allow plenty of time for the examination, but also so that you can have the time to ask any questions you may have to feel comfortable. We will also do our best to perform a cleaning for eligible patients if time allows. In order to allow us to be at your service the full 60 minutes we appreciate if you arrive 15 minutes earlier to complete the new patient registration forms.

Also, we made it possible for you to have access to those forms at your home or office via computer. Please download, print and complete the following form prior to your first appointment in order that we might help you save some time in our reception area.

 

New Patient Online Registration Form

Section 1 of 7 — Patient Information

Basic information about the patient.

Section 2 of 7 — Responsible-Party Information

Information about the person financially responsible for the account.

Section 3 of 7 — Insurance & Financial Information

Insurance details will only appear when applicable.

Primary Insurance Details

Secondary Insurance Details

Insurance Authorization

Section 4 of 7 — Dental History

Please answer the following questions about your dental history.

Section 5 of 7 — Medical History

Please provide accurate health information so the dental team can treat you safely.

General Medical Information

Medical Conditions

Do you have, or have you had, any of the following?

Medical Conditions — Part 1

Medical Conditions — Part 2

Medical Conditions — Part 3

Section 6 of 7 — Treatment Consent & Authorization

Please review the following information and initial where required.

I hereby request and authorize the Dentists, and their staff, to perform dental work upon me for the purpose of attempting to improve my appearance, function and the health of my mouth, teeth, bone, and tissues, as explained above.

I know that the practice of Dentistry is not an exact science, therefore, reputable practitioners cannot properly guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the treatment which I have herein requested and authorized.

I certify that I have read and fully understand the above consent. I have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. I consent to the proposed treatment.

Section 7 of 7 — Signature & Final Confirmation

Review your information, sign, and submit the registration form.

Click here to view the Dental Materials Fact Sheet.

You are signing that you have read and understood it, and that you have received a copy of it.

Signature

Please sign below using your finger, stylus, or mouse.