Now welcoming new patients · Saturday morning appointments available
(555) 014-2200

Maple Dental

42 Maple Avenue, Riverside, Springfield 00000 · (555) 014-2200

New patient form

Please print clearly. Everything you tell us is confidential and used only for your dental care.

About you
Your dental history
Medical history

Tick anything that applies to you. It helps us treat you safely.

Consent

I confirm the information above is accurate to the best of my knowledge, and I will tell the practice if it changes. I understand that treatment and costs will be explained and agreed with me before they begin, and that I can ask questions or stop at any time.

For patients under 18, a parent or guardian signs on their behalf.

Office use: patient number ______ · entered by ______ · fund checked ☐

Call Book an appointment
Demo site · back to portfolio