Cosmetic & Emergency
Terry Hayes DDS, Bryan Benbow DDS, Tina Phan DDS

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
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