• New Patient Enrollment Form - Adults

    Welcome To Our Family at Gentle Family Dentistry!
  • Patient Information

  • Primary Insurance Information

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  • Secondary Insurance Information

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  • Dental History

  • Medical History

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  • For Women Only:

  • Consent

  • I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.


    Payment is due at time of service unless prior arrangements have been made. I understand that I am responsible for payment of services rendered and also responsible of any copay and deductibles that my insurance does not cover.

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