New Patient Forms

Thank you for scheduling an appointment at our office. For your convenience, you may download and complete the New Patient Form prior to your first visit. This will save you a few minutes in the waiting room.

Download the Dental Health History form (PDF) – Right-click and Save as/Save link as…

To complete the Health History PDF form, download and save the file to your Desktop. The form is in PDF format and may be completed with Adobe Acrobat Reader.

To complete the Health History form on your mobile devices. Adobe Acrobat Reader from the Google Play Store or from the Apple App Store is required.

After you’ve completed and saved the form, you may print them and bring them to our office on your first visit or email them as an attachment to info@dsaot.com.

Important Notice

Dr. Burchard and the Dental Surgical Arts team are concerned about your personal and medical privacy. If you choose to email your patient forms to our office, you should be aware that while many top-level email systems are password-protected and secure, not all email correspondence is encrypted and your personal information may be visible to third parties (like your internet service provider, employer or another account user.) If you are not sure about the security of your email account, please bring a printed copy of your forms on your first visit. If you choose to email your forms to our office, we are trained to manage all patient correspondence and medical information according to HIPAA regulations.