Patient Forms

For your convenience, please download the PDF fillable forms and save, fill all applicable sections and then email to info@greatlakesdental.net with your name in subject line. On an average it will take at least 15-20 minutes to fill these forms at the office. Please plan on arriving accordingly to your first appointment.

Please update us if there are any changes to your health status, insurance and/or contact information.

Para su comodidad, descargue los formularios que se pueden completar en PDF y guárdelos, complete todas las secciones correspondientes y luego envíe un correo electrónico a info@greatlakesdental.net con su nombre en el asunto. En promedio, tomará al menos 15-20 minutos completar estos formularios en la oficina. Planee llegar en consecuencia a su primera cita.

Actualícenos si hay algún cambio en su estado de salud, seguro o información de contacto.

New Patient Forms

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Patient Registration Form

English and Spanish
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Medical / Dental History

Print in Landscape only

Existing Patient Forms

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Recall History

English and Spanish

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Consent for Treatment

English – Page 1; Spanish – Page 2

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Dental Implant Consent

English

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Dental Implant Consent

Spanish

For Information Purposes

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Office & Financial Policy

English – Page 1; Spanish – Page 2

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Patient Care Instructions

English – Page 1; Spanish – Page 2

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HIPAA Notice of Privacy Practice

English

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HIPAA Notice of Privacy Practice

Spanish

What to expect at your first visit:

— Verification of personal information, health history and benefit plan / insurance coverage
— Exam, X-rays, pictures, consultation and simple teeth cleaning (if applicable)
— Topical fluoride (Kids), oral hygiene instructions and patient samples
— Discuss treatment plan and insurance breakdown for payments
— Follow-up treatment / recall visit appointment