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New Patient Registration Forms

Welcome to our practice!  Please complete the Patient Registration and Health History, the Financial Policy, and the HIPAA Acknowledgement Form.  Please bring these with you to your first appointment. 

Patient Registration and Health History 02192015.pdf

Child Patient Registration and Health History.pdf  (Parent/Guardian should complete this form if the patient is under age 14.)

Financial Policy.pdf

HIPAA Acknowledgement Form.pdf 

HIPAA Acknowledgement Form for Minors.pdf   (Parent/Guardian should complete this form if the patient is a minor.)

The HIPAA Privacy Notice is included below for your review.  You do not need to print this document or bring it with you.

HIPAA Privacy Notice.pdf 


 We look forward to meeting you at your dental appointment!  Thank you for choosing our practice!

96 Old Mill Road|Martinsburg, WV 25401|MAP & Directions

Call: 304.263.0707