Patient Forms

The first visit to our office is designed to get you better acquainted with all we offer as well as introduce you to Dr. O'Dell and our caring staff. We encourage questions and do our best to always deliver quality care.

Please take a moment prior to your scheduled appointment to download and fill out our patient forms. We ask that you complete the forms prior to your appointment so we may better assist you in a timely manner.

Thank you for your confidence in our office, we look forward to assisting you with all your dental needs.

Patient RegistrationMedical History
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Welcome to the New Patient Form

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PATIENT REGISTRATION

This section contains all information about you, the patient.

Responsible Party (If not Patient)

Contact Number(s)

Date of Birth

Your Insurance Information

Here we will collect your primary and secondary insurance information (if available)

Responsible Party (person to be billed)

The person specified in this section is financially responsible for any payments your insurance will not cover.

Date of Birth

Primary Care Physician Information

Referring Physician

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PRIMARY INSURANCE INFORMATION

Name of Insured

Insured Date of Birth

Employer

Insured Company

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SECONDARY INSURANCE INFORMATION

Name of Insured

Insured Date of Birth

Employer

Insured Company

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Submit Your New Patient Form

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