Patient Dental Forms

The following forms are available to be completed online for New Dental Patients:

  • Patient Demographic Form
  • Patient Contact Form
  • Medical History
  • Informed Consent
  • Patient Rights and Responsibilities Statement
  • Notice of Privacy Practices Acknowledgement Form
  • Patient Discount Program Application
  • Patient Discount Program Income Chart (2021)

Important Instructions for Fillable PDF Files: 

  • Fillable PDF forms will require the free Adobe Acrobat Reader software or smartphone app.
  • Please download the fillable PDF to your computer or device before filling out your information.
  • Once a form is filled out, please save your file before sending to OHHS. To save a PDF, choose File > Save or click the Save File icon  in the toolbar at the bottom of the PDF. 
  • When ready, click the "E-mail Form to OHHS" button. This will prompt you to select a default mail application, such as Outlook, or to use a Web mail service, such as Gmail. Please select the option that is configured on your device.
  • iPhone and smartphone users may need to "share" the PDf to open it in the Adobe Acrobat Reader app. Please be sure to download the free app before using the "share" feature.