Forms

We would like to welcome you to the Miami County Dental Clinic!

Your first step to quality, affordable dental care is calling us and setting up an appointment with one of our dentists/hygienists. (937) 339-8656

The next step as a new patient would be to complete our 3 new patient forms. You can certainly just show up early for your appointment and complete these forms, or you can print them out and complete them at home, many times making your first visit to our office even more speedy!

Medical History Form

By completing this form, your dentist will gain a better understanding of your overall health, the medicines you may be taking, as well as your lifestyle choices. All of these are important factors to your overall oral health.

MedicalHistoryMCDC

Patient Registration Form

This form will provide us with the basic information that we need to contact you for future appointments and identify your form of insurance (if any).

PatientRegistrationFormMCDC

Consent for Treatment Form

This form is a consent form for the release of medical information. This form also communicates our appointment rules as well as patient financial responsibility.

ConsentToTreatMCDC

*NEW! No Show Policy

In order to provide the maximum amount of quality care for all of our patients, we ask that you refer to our No-Show Policy. This is also posted within our offices for your reference.

No-Show Policy

*NEW! Self Pay Information

Please refer to this form and complete it prior to your visit to expedite your check-in and dental appointment.

Self-Pay Information