New Patient Forms

New Patient Forms

Thank you for choosing Gordon Dentistry. We strive to provide you with the best possible dental care. The following dental patient forms are designed to help us meet all your healthcare needs. Please fill out the appropriate dental patient forms completely. If you have any questions or need assistance, please ask us — we will be happy to help. Please choose from the links below to download and complete the medical information and dental patient forms in advance and bring with you to our office.

Patient First Visit

Your first visit to Gordon Dentistry establishes a vital foundation for our relationship. During your first visit, we will review your medical history and document any medications or herbal supplements you may be taking so that we are aware of any conditions that may impact your oral health.

You can save time at your first visit by completing and printing out the dental patient forms in advance of your appointment.

Mutual Agreement Form

This serves as an agreement between our office and you regarding our policies on treatment planning, appointment times and payment policies. Click below to download the Mutual Agreement Form.

Notice of Privacy Practices HIPAA

The Health Insurance Portability and Accountability Act of 1996 (HIPAA; Pub.L. 104–191, 110 Stat. 1936, enacted August 21, 1996) was enacted by the United States Congress and signed by President Bill Clinton in 1996.

For your information only. Please do not print.


So that we may verify your dental insurance benefit, please email a copy of the front and back of your insurance card to [email protected] We will contact your insurance company and verify whether we will be an in-network or out-of-network provider for you. If you do not have an insurance card, you can provide us with the following to verify your benefits:

  • Patient Name, DOB, Subscriber number or Social Security number
  • Insured person’s name, DOB, Subscriber number or Social Security number
  • Employer Name and Group number
  • Insurance Company Full Name (Example – Delta Dental of Illinois)
  • Insurance Company Phone Number
  • Claims Address
  • Payor ID

Antibiotic Prophylaxis

The American Heart Association updated their recommendations for antibiotic prophylaxis to prevent infective endocarditis in April 2007. The following conditions warrant antibiotic prophylaxis: prosthetic cardiac valves, history of previous infective endocarditis, severe or unrepaired congenital heart disease, completely repaired congenital heart defect with prosthetic material or device during the first six months after the procedure, repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device, cardiac transplantation recipients who develop cardiac valvulopathy. Patients with a history of heart attack or stents or bypass surgery generally do not require antibiotic prophylaxis. Click below to learn more.

For your information only. Please do not print.

Total Joint Replacement Form

Click below to download the Total Joint Replacement Form.

Complimentary Xrays

We will take any needed x-rays at no charge during your new patient appointment. Please allow 60 to 90 minutes for a comprehensive examination of your teeth, gums and soft tissue. Up to a $275 value! New patients only. Not valid with any other offer. ADA Codes D0150, D0210, D0272, D0330.


    No, thank you.