FIRST VISIT FORMS

Mayfield Smiles First Visit Overview & Patient Forms

Your first appointment will consist of an examination and overview of your treatment options. Depending on the results of your exam and your treatment plan, we are typically able to provide same-day treatments (or at least get started). If you have a complex medical history or treatment plan, this will require an evaluation and a follow-up appointment to continue treatments. 

Patient Health History

In order for us to effectively treat you, we need your previous dental medical records and X-rays as well as any preexisting medical conditions, insurance, etc. This will allow us to get you in and out quickly, process any claims and save you chair time!

  • Previous X-Rays: If your previous dentist or physician has taken x-rays recently, these can be requested to be sent to our office. If there is not enough time, please request to pick these up and bring them to our office on the day of your appointment. We can take additional x-rays in the office if need be.

  • Pre-Existing Conditions: Diabetes, high blood pressure, artificial heart valves and joints, rheumatic fever, etc.

  • List of Current Medications: Medications including heart medications, aspirin, or anticoagulant therapy. 

Reminder: Patients under 18 years of age must be accompanied by a parent or guardian. 

Two women standing behind a reception desk, smiling at the camera in a cozy, well-lit office or clinic setting.

New Patient
Form

Click the button below to fill out the New Patient Form.

NEW PATIENT FORM

Financial Policy Form

Click the button below to fill out the Financial Policy Form.

FINANCIAL POLICY FORM

Patient Consent Form

Click the button below to fill out the Patient Consent Form.

PATIENT CONSENT FORM

Child Health History Form

Click the button below to fill out the Child Health History Form.

CHILD HEALTH HISTORY FORM

Committed to Clean & Safe Care

Mayfield Smiles strives to provide a clean, safe and comfortable environment that protects clients and team members alike and helps control the spread of infections. Patients can rest assured that we follow the guidelines from the Occupational Safety & Health Administration (OSHA), the Environmental Protection Agency (EPA), the Centers for Disease Control (CDC),and the Ohio State Dental Board, as well as others to ensure the safest, most comfortable environment possible.