• Adult New Patient Information & History

    Adult New Patient Information & History

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  • Health Care Professional(s)

  • Dental Insurance Information

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  • Epworth Sleepiness Scale

    How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired?
  • This refers to your usual way of life in recent times.

    Even if you haven't done some of these things recently try to work out how they would have affected you.

    Use the following scale to choose the most appropriate number for each situation:

    0 = would never doze
    1 = slight chance of dozing
    2 = moderate chance of dozing
    3 = high chance of dozing

    It is important that you answer each question as best you can.

  • Notice of Privacy Practices

  • Health Information Access

    Note: If you wish to add or teminate information access to or from the list below, you must submit your request in writing to our office.
  • Signature

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