Patient Center › New Patient Forms

New Patient Forms

Please fill in the forms and submit them before your appointment so your visit is easier. You will sign the forms electronically when you are here at our office.

Patient Registration Form

Your contact details, responsible party and insurance information.

Request this form

Patient Financial Agreement

How payment, insurance benefits and financing arrangements are handled.

Request this form

HIPAA

Notice of privacy practices and your acknowledgement of receipt.

Request this form

Medical History Form

Conditions, allergies and current medications so treatment can be planned safely.

Request this form

Questions before your first visit?

Call us at (904) 272-7277 or email info@jaxcosmeticdentist.com and our team will help.

Request an appointment Insurance & financing