Dental Forms

Plum Grove Dental Associates - Dental FormsPrior to your appointment, please click on the appropriate forms below, download, and print. Completely fill out the forms prior to your office visit and bring them with you.


    • New Patient Packet (4 pages) (PDF)


    • Notice of Privacy Practices Omnibus Rules (HIPAA) (PDF)


    • Minor Patient's Parent Information (PDF)
      (please print and fill out if the new patient is under 18)


    • X-Ray Request Form (PDF)
      (if you would like to request x-rays from your previous dentist, please print and fill out)


    • Records Release Request (PDF)
      (if you are an existing patient and transferring to another office or moving, please print and fill out)


    • Communication Information (PDF)


  • HIPAA Receipt & Release Page (PDF)

All documents are Adobe Acrobat PDF format Adobe Acrobat PDF Reader.  You can download the free Adobe Acrobat Reader application here [link].  (note, uncheck "Optional Features" boxes before clicking Install Now)