New Patient Forms

The form links below are for your convenience. They give you the opportunity to read our policies and notices in the comfort of your home. Informational forms can be completed in advance, so bring them with you to your first appointment. If you have any questions, please contact Tanya at 503-646-3169.

Click on the form name to download a copy.


Please fill out these forms and bring them with you to your first appointment. Thanks!

>> Patient Information Form

This form details your patient history.

>> Dental History Form

This form details your dental history.

>> Medical History Form

This form details your medical history.

>> Financial Policy Form

This form shares our financial policies with you.

>> Privacy Notice Form

Read this to understand important information about your privacy.

>> Privacy Acknowledgement Form

This form acknowledges your receipt of the Privacy Notice form.



Additional Forms


>> Authorization to Disclose Medical Records Form

This form allows you to designate who your medical records may be disclosed to. Fill it out and bring it to your first appointment. Thanks!











        

Appointment Request Form

Click here to schedule an appointment

Did you know?

Chewing gum with the ADA-accepted seal will protect your teeth. It stimulates salivary flow, neutralizes acids produced by cavity-causing bacteria and washes out food particles to help keep your teeth strong and healthy by reducing demineralization.

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Dennis Simonsen DMD - Simonsen Dental | www.simonsendental.com | 503-646-3169
14125 SW Farmington Rd, Beaverton, OR 97005



 

 

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