Forms

The following forms are for patient use.  If you are a doctor, please use the forms in the doctor resources section.

Patients, please print and fill out the appropriate forms.  You may bring them in with you to your appointment, or mail them to us.  Our mailing address is: 1000 Brooktree Road, Suite 304, Wexford, Pennsylvania 15090

  Consent for Use and Disclosure of Health Information
Better known as HIPAA, we need this document in order to share your treatment information with your other health care providers (MS Word format).

  Consent for Use and Disclosure of Health Information
Better known as HIPAA, we need this document in order to share your treatment information with your other health care providers (PDF format).

  Dental History Form
Please use this form to let us know why you are seeing the doctor.

  Directions to Dr. Werkmeister's Office

  Health History Form
Information about your previous dental health history for our records (MS Word format).

  Health History Form
Information about your previous dental health history for our records (PDF format).

  New Patient Registration and Insurance
New patient information and insurance information (MS Word format).

  New Patient Registration and Insurance
New patient information and insurance information (PDF format).