Patient Forms

If you are a new patient or need to update your information, please complete the appropriate forms before arriving to allow us to attend to your medical needs more quickly than completing them on your arrival. Thank you and please call our office if you have any questions at all.

 

Wellness Form (For All Patients Before Visit)

Wellness Form


 

New Patient Packet Online Forms

Click here to complete your new patient online forms (all forms required for New Patients)


 

Individual Online Forms

Patient Information Form

Medical History Form

HIPAA Notice of Privacy Practices Form


 

Printable Forms

Adult Patient Information Form

Child Patient Information Form

Medical History Update Form

HIPAA Notice of Privacy Practices Form

HIPAA Receipt Form

Medications List Form

Financial Policy Form

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.

 

Contact Us

Call our office at 812-280-7500 or use the quick contact form below to schedule your appointment.

Now Welcoming New Patients!

For emergencies or immediate assistance, please call 812-280-7500.

Testimonials

Always wonderful. Love the friendly kid loving staff who always take such great care of my whole family. Been going here for years. I couldn't imagine ever having to go to another dentist. Thanks for such a great experience every time we come in. I never would have thought a kid would say "when do we get to go the dentist again", but both of mine do.

B. Keen

I absolutely hands down love this place. They are caring and always make you feel OK! Best dentist I've ever been to. Think I'll stay at this one!

J. Swarens

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Office Location

  • Jeffersonville
  • 4100 Woehrle Rd
  • Jeffersonville, IN
  • 47130
  • Map & Directions
  • Call: 812-280-7500
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