303 East Main Street, PO Box 285 | Mount Horeb, WI 53572

608.437.5519

New Patients

Welcome to our office!

 

For each new patient, please fill out, print and bring the following forms with you to your first appointment.

 

We can also mail forms to you if you'd prefer. Please call our office to make arrangements.

 

If you are unable to do so, please arrive 15 minutes prior to your appointment to fill out the necessary paperwork.

 

 

 

Forms

Patient Information Form

 

Medical History Form

 

Dental History Form

 

HIPAA Consent Form

 

Record Release Form

 

 

The following form is optional to print and is for your reference only.

 

Updated Notice of Privacy Practices

 

Updated Notice of Privacy Practices (en español)

 

 

Thank you. We look forward to meeting you and welcoming you into our dental family.

 

GET IN TOUCH

301 East Main Street | Mount Horeb, WI

608.437.5519

Mt Horeb Dental is proud to serve the following areas around Mount Horeb, WI:

Verona, Dodgeville, Oregon, Fitchburg, Middleton, Sauk City and more