Cosmetic & Emergency
Dentistry
Terry Hayes DDS, Jessica Jordan DDS, Jane Moore DMD

New Patient Forms

To help us maintain accurate patient records, prior to your first dental visit you will be asked to furnish our office with information such as your dental condition, medical history, insurance and/or the responsible party for payment, etc.

A Time-saving Option

You may complete the forms at our office, or you can save some time by choosing to download, print and fill them in from the comfort of your own home. Then simply bring the completed paperwork with you on your first appointment.

Downloading Our Printable Forms

Although it is not required to complete the forms in advance, this is a convenient way for you to reduce the time spent in our office before your first dental exam/treatment.

If you are unable to download these forms, feel free to call our office and we will be happy to mail or fax them to you.

Please complete the forms as thoroughly as possible and if you have questions or problems, our staff can assist you with any incomplete information when you arrive. 

New Patient Form

Have Questions? Get in Touch
If you have difficulty using our website, please email us or call us at (901) 850-0700
View the ADA Accessibility Statement
Our Team at Hayes Cosmetic & Emergency Dentistry is well aware of the situation we as a community are facing. We understand the concerns, and uneasiness surrounding coronavirus (COVID-19), and we are continuing to monitor it. Our doors will remain open; to assist our patients in need of emergency dental care and in our community. Please call us right away if you are experiencing a dental emergency.

We want everyone to know that we always follow universal protocols, for the safety and care of our patients and staff. Hygiene standards for our patients, office environment and the team will always be a top priority. We are implementing a screening process for everyone in the office, including inquiring on whether they have been to certain countries in the past 14 days or have come into contact with anyone who has and whether they have experienced any flu-like symptoms within the past 14 days. Should anyone respond yes to any of the above, we will be rescheduling appointments and/or sending them home. Our team is here to assist you in all ways from continuing to provide you dental care and accepting any emergency patients.