New Patient Forms

New patients will be required to furnish us with the following information prior to their first visit.

This information will include:
  • Patient Information
  • Emergency Contact Information
  • Insurance Information
  • Cancellation Policy Acknowledgment
  • Medical History
  • Dental History
  • Consent for Treatment Form
  • Acknowledgment of Privacy Practices
  • Financial Arrangements

If you would like to fill out and print your new patient forms prior to arriving at the office, please download the following document:

New Patient Forms.pdf - Included in this PDF is our Client Information Form, Medical Information Form, Consent for Treatment Form, Acknowledgment of Privacy Practices, and Financial Arrangements Form

Testimonials

I am extremely impressed with Southern Smiles and Dr. Alex Krempa and his staff! Everyone is so friendly and I feel so comfortable for the first time at a dentist office! I am so grateful my friend who recommended him! I live across the bay and they are well worth the drive! Thanks again southern smiles!!!!! ;) -Mandi Chadwell (4-10-14)

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