New Patient Forms

The New Patient form is in PDF format, which can be read using Adobe Acrobat Reader. If you do not have Adobe Acrobat Reader, get a free copy by clicking on the link below.

When you have Acrobat Reader, click on the link below to download the New Patient form. (If you are on a dial-up modem connection, please be patient - it may take several minutes). Then print the form, fill it out, and bring it with you on your first visit. Also, after reading the Notice of Privacy Practices, print the Acknowledgement form below, sign it, and bring it in, too.

Adult Form

Child Form

Acknowledgement of Receipt of Notice of Privacy Practices (web page)

© Copyright 2003- Dental WebSmith, Inc. and John R. Loar, DDS & Associates. All rights reserved. Disclaimer: The information provided within is intended to help you better understand dental conditions and procedures. It is not meant to serve as delivery of medical or dental care. If you have specific questions or concerns, contact your health care provider.