The Dental Place
The Dental Place

Patient Forms

New patient? Please download and fill out the following forms when you come in for your first appointment.

Patient Medical History Form

This form is mandatory for new patients. To expedite your visit, print this form, fill it out and bring it with you for your first visit.

Patient Medical History Form
health hx.pdf
Adobe Acrobat document [108.6 KB]

Adult Form

This form covers general information about yourself so that we can get to know you better. This form should also be brought to your first appointment.

Adult Form
Adult form.pdf
Adobe Acrobat document [62.9 KB]

Child Form

This form covers general information about your child so that we can get to know your child better. This form should also be brought to your first appointment.

Child Form
child form.pdf
Adobe Acrobat document [68.8 KB]

Privacy Notice

Please read over and sign our Notice of Privacy Practices, acknowledging our privacy policy. This form should also be brought to your first appointment.

Privacy Notice
HIPAA Privacy.pdf
Adobe Acrobat document [90.0 KB]

Financial Policy

Please read over and sign our Financial Policy. This form should also be brought to your first appointment.

Financial Policy
Financial policy.pdf
Adobe Acrobat document [89.0 KB]

Medical Release Forms

Please read over and sign. Due to HIPAA privacy policies, if you have information or childrens information that must be sent beyond this facility this form should be filled out to give us permission to share this information with whom you allow. Also, these forms allow us to treat your minors. This form should also be brought to your first appointment.

Medical Release Forms
Medical release forms.pdf
Adobe Acrobat document [99.8 KB]

Preferred Information

This information gives us a little more information to fine tune your Dental experience. This form should also be brought to your first appointment.

Preferred Information
Preferred Information.pdf
Adobe Acrobat document [41.2 KB]

Make an Appointment Today!

Call us at: (361) 643-2522

 

The Dental Place

213 Cedar Dr Suite C

Portland, TX 78374

Fax:(361) 643-1266

dr.j@thedentalplacetx.com

 

Use our contact form to get in touch.

Office Hours

Monday through Thursday :

8:00 am to 5:00 pm

Lunch: 12:00 pm to 1:00 pm

 

Friday: 8:00 am to 12:00 pm

Keep Your Teeth Healthy!

What is the best preventive care for your teeth? Find out how to make your next visit easier and more pleasant.

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