Patient Forms

Demographic Information and Medical History Form (for New Patients only)

Please take a minute to print and fill out the patient information form before your first appointment:

• Demographic Information and Medical History Form /hub_sites/cassinelli-alex/www/assets/uploads/files/New%20patient%20history%20form.pdf

Annual Medical Update Form (for current patients only)

Please take a minute to print and fill out the patient information form before your next appointment:

• Annual Medical Update DOC

Dental Insurance Form

Please fill out our Insurance form and bring it with you to your first visit.

• Insurance Form DOC

ACH Debit Form

Our office gives you the option to have payments automatically withdrawn from your checking or savings account.

• ACH Debit Form DOC

Credit Card Authorization Form

Our office gives you the option to have payments automatically charged to your credit card.

• Credit Card Authorization Form  DOC

No-No Foods List

Print out our list of foods we recommend you stay away from while wearing braces.

• No-No Foods List DOC