New Patient Form

Tooth Works Dentistry would like to welcome you to our dental practice.

In your new patient exam, we will examine your teeth, gum tissue, the function of your jaw joint, obtain a digital scan of your teeth and perform an oral cancer screen. Together we will discuss our findings and develop a treatment plan.

We are happy to help you submit dental claims to your insurance. If dental claims do not specify amount payable to our practice on day of treatment, you will be responsible for the payment. We accept Visa, MasterCard, American Express, Debit.

Please fill out and submit the form below with your personal information/medical history and consent form. If you have dental benefits, please bring your coverage information with you and to this initial visit as well.

New Patient | Tooth Works Dentistry

Personal Information Consent Form

We are committed to protecting the privacy of your personal information and to using it in a responsible and professional manner.

Personal information is used to open and update patient files, to contact patients for follow-up treatment and to process dental benefit claims. We also contact patients about relevant changes or updates within our practice.

Financial information is used to process payments for our services, to process claims for third party providers/dental insurance companies and collect unpaid accounts.

Medical and dental information is used to diagnose and treat dental conditions, safely and appropriately.

  • I, certify that I have provided an accurate and complete personal and medical – dental history and have not knowingly omitted any information.

  • I authorize the dentist to perform diagnostic procedures and treatments as may be necessary for my dental care.
  • I also understand that consultation with my medical doctor may be required and I consent to my physician being contacted if necessary.
  • I consent to photographs being taken during the course of my treatment.
  • I consent that in the event of a needle stick injury to our staff during your dental treatment, that I will submit to a laboratory blood test to screen for any blood-borne communicable diseases.