New Patients 727-888-6929

Existing patients 727-446-6747

127 N Garden Ave, Clearwater
FL 33755 | Directions

Appointments / Patient Forms

Please fill out the Appointment Form as the first action, which contains your contact information. Please click on the box which represents your area of concern.

Below the Appointment Form, there are additional forms to be completed which give your health history. Since the toxicity in the mouth and the structure of the jaw and bite can affect the whole body, knowing your health history is vital.

Make sure to fill out all the form in one sitting and hit the [Send Button] before leaving the page.

We look forward to hearing from you and being able to apply Natural Dentistry procedures and approaches which, we believe, will put you in control of your dental health once again.

Option 1: Open the form in your internet browser (IE or Chrome), fill it online, print out the completed form, and bring it when you come for your appointment.

Option 2: Open the form in your browser, download, open it in Acrobat reader, fill in details, click submit by email and follow instructions.

Option 3: Open the form in your browser, download, open it in Acrobat Reader, fill it in, save, attach the saved document to an email and send it to us

If you have trouble viewing the forms, please download and install Adobe Acrobat Reader by clicking link https://get.adobe.com/reader/

If you have already requested an appointment you can fill out the first time visit forms here.

New Patient Information Forms

Patient Information

Request for Chronological Health

Chronological Health History Work Sheet

Scheduling Policy

Kinesiology (Muscle Response Testing) Informed Consent

Amalgam Removal Informed Consent

Notice Of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

Musculoskeletal Screening Questionnaire

Epworth Sleepiness Scale

Authorization to Contact

Insurance

What would be Involved in a Visit

  1. X-rays and examination of your oral condition.
  2. Make an Appointment By Filling in the blanks and hit [send]
  3. Print and fill out these Intake forms and bring them in with you.
  4. We are a Fee for Service Office meaning we do not accept payment from dental insurance companies. However we can help you with everything you need to file a claim with your own insurance company.

Appointment Request Form

Fill out my online form.