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New Patients

Hello! We are so glad you're here and look forward to meeting you!

We encourage new patients to print the forms listed below (7 pages in all) and complete them prior to your first appointment with us.  This will save you time at the initial visit which typically includes radiographs, comprehensive exam and periodontal screening. 

 

At your first visit, please remember to bring:

* all completed paperwork

* list of all medications you are taking

* dental insurance card 

 

 

 General Information- page 1 

Dental Information / Allergies- page 2

Medical Conditions- page 3

Pharmacy / Medications- page 4

Dental Insurance Information

Consent & Acknowledgement 

HIPPA Compliance

 

 

Notice of Privacy Practices * This form does not need to be printed for your visit;  it is for your records only.

Crafted by Zibster
Open Mon-Thur
8am - 4 pm
Phone: (681) 318-3427
Fax: (681) 318-3429
Open Mon-Thur
8am - 4 pm
Phone: (681) 318-3427
Fax: (681) 318-3429
Dr. A. Charles Lilly, DDS Logo
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  • HOME
  • ABOUT US
  • OUR SERVICES
  • NEW PATIENTS
  • CONTACT US
Open Mon-Thur
8am - 4 pm
Phone: (681) 318-3427
Fax: (681) 318-3429