Periodontal Patient Information, Milwaukee, WI

Medical and Dental History

You can choose to print and fill out the following forms and bring them to our office the day of your  examination appointment  OR  you can fill out these forms at your examination appointment.

• Patient Medical/Dental History Form

• Patient Registration Form

• HIPPA Form

• Insurance Authorization Form

  
  Formulario en Español

• Historial Medico y Dental del Paciente

• Autorizacion de Pago

• Consentimiento de Procedimientos y Tratamiento

• Reconocimiento de Recibo

We accept the Care Credit financing plan that has been endorsed by the Wisconsin Dental Association. This plan enables patients to borrow money for dental treatment interest-free during the first twelve months of the loan.

We are a Delta Dental Premier Provider

New Patient Registration

Please bring the following information with you to your first appointment:

1. Insurance cards, both Medical and Dental

2. Policy holder's Social Security number and date of birth

3. Physician's name and address

4. Any prescriptions you're taking

5. Your family dentist's and your previous dentist's name and address

6. We will contact your referring dentist for x-rays

7. Patient portion not covered by your insurance should be paid on day of appointment