Printable Forms Printable Forms Below

For your convenience, print and fill out the three forms below in the comfort of your home. Bring the completed forms with you on your first visit. Your choice of format.


Dental Registration and History


Financial Policy


Informed Consent Form for General Dental Procedures

 

Your First Visit

Your initial appointment will consist of an examination, evaluation and a consultation explaining your diagnosis and treatment options. Occasionally, treatment can be done the same day as the consultation. Normally, however, a second appointment will be required to begin your treatment plan.

Prior to your dental exam, you will need to provide information that will assist us in developing a dental care treatment plan for you. You need to fill out/sign the following forms::

Printable Forms
  • Dental Registration and History
  • Financial Policy - Please present your insurance information at this time - If you have medical or dental insurance, bring the necessary completed forms.
  • Informed Consent Form for General Dental Procedures

For your convenience, required forms are printable in multiple file formats.

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A parent or guardian must accompany all patients under 18 at the consultation visit.

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It is extremely important that you alert us to any medical condition for which you are currently under the care of a doctor. Please let us know of any existing medical conditions that may be of concern prior to surgery (i.e. diabetes, high blood pressure, artificial heart valves and joints, rheumatic fever, etc.) or if you are on any medication (i.e. heart medications, aspirin, anticoagulant therapy, etc.) or require medication prior to dental cleanings (i.e. antibiotics, for pre-med).


Member American Dental Association
LOCATION
1422 Lincoln Way East
South Bend, IN 46613
Tele: 574.232.8888
Tooth with Toothbrush
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OFFICE HOURS
Mon - Wed: 8 am - 5 pm
Thurs - Fri: 8 am - 1 pm
Saturday - Call for appointment
Member Academy of General Dentistry