(208) 756-2899

Let's Begin!

Fill out this form online and we will have it ready for you to sign when you come in.

Patient Information

Insurance Information

Health History

Have you had any of the following? Please check those that apply:

Are you allergic to any of the following?


Has your medical physician recommended you take an antibiotic prior to dental work?

i.e. Latex, Penicillin