New Patients (330) 969-6343

Current Patients (330) 343-2555

541 Wabash Avenue Northwest New Philadelphia, OH 44663

New Patient Documents

New Patient Questionnaire Instructions

Thank you for your help completing the important, if somewhat unpleasant, task of filling out a questionnaire prior to your first visit! Providing us the detailed information on this questionnaire allows our team to custom-tailor your dental visit according to your individual preferences and needs; it also helps us keep you, other patients, and our team members safe.

We don’t like spending time on paperwork either; we get it! Therefore, our promise to you is that you will not be asked even one unnecessary question, as we have hand-crafted all our documents from scratch to ensure each is as straightforward, brief, and convenient as possible. Although you would be forgiven for being skeptical in this moment, as we’re asking for a substantial amount of your time, your comfort and care are truly our highest priorities 🙂 If we can assist you at any time while you are filling out the questionnaire, please do not hesitate to call 330-343-2555, option 2 for “Amanda and Melissa at the front desk,” or reach out to Amanda and Melissa via email at, and we will gladly assist you!

Please allow 45 minutes to an hour to complete all documents in a questionnaire. We have provided a link to each document below the “New Patient Questionnaire” headings. They can be filled out electronically on any device, at your convenience, and in the privacy of your own home. To complete a document, click on its title, provide the information requested in the various fields, sign in the signature boxes, and click “Submit” or “Register” as the final step. While most of the fields are required, certain fields (those not marked with an asterisk) are optional. You will see a ‘Skip’ button at the top right corner of some of the documents; please do not use it unless it’s to skip the “Dental X-Ray Release” section of the Dental Health Information document, as all the documents on these particular questionnaires are required. Please don’t use your browser’s Back or Forward buttons. Use of these buttons may ‘undo’/’redo’ your recent actions and may result in errors.

Once submitted, the information will be securely and automatically transmitted to our practice (you don’t have to print the forms or bring any information with you to your appointment). When we have received your entire questionnaire, we will process it and then reach out to schedule your new patient appointment!

Again, we appreciate you providing us this valuable information which helps us deliver outstanding care! Here’s that contact info again in case you need our assistance! Email or call 330-343-2555, option 2 for “Amanda or Melissa at the front desk.” 


Adult New Patient Questionnaire: 6 Documents ℘

Let’s Start With The Fine Print For Adults
Adult General Patient Information
Adult General Health Information
Adult Medication and Allergies 
∗ This document will ask for your “Appointment Date” – please use Today’s Date in that field 
Adult Dental Health Information
Adult Patient Billing Registration


Child New Patient Questionnaire: 7 Documents ℘

Let’s Start With The Fine Print For Children
Child General Patient Information
Child Medication and Allergies 
∗ This document will ask for your “Appointment Date” – please use Today’s Date in that field 
Child General Health Information
Persons Authorized to be Involved in Your Child’s Care
Child Aged 0-3 Dental Health Information
Child Aged 4-13 Dental Health Information
∗ Based on your child’s age, please choose and then complete a document from the 2 choices above 
Child Patient Billing Registration



Authorization to Release Protected Health Information Instructions

If you need to complete the document which will allow us to access your dental records from your previous dentist, you are in the correct place!

The link below will take you to an “Authorization to Release Dental Information” form. It can be filled out electronically at your convenience and in the privacy of your own home. Once submitted, the information will be securely transmitted to our office, which will allow us to prepare for your visit.

Our forms are compatible with any computer, laptop, tablet, or smartphone!

Please complete a form for each member of your family who will be joining our practice; allow around 5 minutes per person to provide the necessary information. Thank you!

If you have any questions, please feel free to reach out to Amanda at, and she will be happy to assist you.

Authorization to Release Dental Information