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New Patient Forms

Thank you for choosing Midwest Dental. For your convenience, this section includes forms you'll need during your first visit, as well as what to expect when you come in for your appointment. If you still have any questions about your upcoming visit, please call your Midwest Dental office. We're here to help.

Please complete the following information. Be sure to bring these forms to your first appointment. The HIPAA Acknowledgement and Authorization for PHI Disclosure form acknowledges that you have received the form. It also provides instructions to Midwest Dental about who, if anyone, we may disclose information about your treatment.

Adult Patient
Health History Form

Download Form

Child Patient
Health History Form

Download Form

HIPAA Acknowledgement
and Authorization

Download Form

Midwest Dental Financial Policy

Please read, agree to, and sign our financial policy prior to any treatment.

Download Form

Pre-Medication
Requirements

Patients with certain medical conditions may need to take medication before seeing the dentist.

Download Form

About our
Privacy Practices

We are required to provide you with information about our procedures to safeguard your personal information.

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Day of Your Appointment

Please arrive 15 minutes before your scheduled appointment. This will allow us to finish any paperwork and stay on schedule with your appointment. Please bring the following items with you to your first appointment: