New Patients
Patient Form
Download the new patient form, fill it in at home, and bring it to your first visit. It saves you time in the waiting room and gives Dr. Prasol your health history before treatment begins.
New Patient Form
Patient information, financial information, and health questionnaire
Download Patient FormHow It Works
- 1
Download and Print
Print both pages. The form is double sided, so please complete both.
- 2
Fill It In at Home
Take your time with the health questionnaire. Keep your insurance card and a list of any medications nearby.
- 3
Bring It With You
Hand it to the front desk when you arrive, or email it ahead to appointment@saugusdental.com.
What the Form Covers
- Patient Information
- Name, date of birth, contact details, employer, and the person responsible for the account.
- Financial Information
- Preferred method of payment plus primary and secondary dental insurance details.
- Terms and Conditions
- Financial arrangements, assignment of insurance benefits, and your signature.
- Health Questionnaire
- Medical history, current medications, allergies, and your dental history.