Patient Forms

Prior to completing your New Patient Form, please take a moment to review the following policies as you will be asked to electronically sign that you have read and understand the office policies of Smiles by CDO. You are not required to print and sign each form.

For existing patients, please complete a Medical History Update prior to each re-care appointment at Smiles by CDO. You may turn this form in at your appointment check-in.

* required field

Patient Dental History

In order to ensure your/your child’s safety, comfort and happiness during dental treatment, we need to obtain information from you. Please carefully and completely answer the questions below. Thanks!

Patient Dental History

Family Dental History

Cavity Prevention History

Growth and Development

Patient Medical History

Responsible Party Information

Responsible Party #1

Responsible Party #2

Permission is hereby granted to the doctor and staff to perform an initial dental examination and treatment which may include preventive education, x-rays, dental cleaning, fluoride treatment, and orthodontic consultation.  (Note: Some insurance plans may not cover some procedures due to age/frequency limitations. Our office gives you an estimate of charges for treatment appointments; actual charges may differ due to conditions found during treatment. Please remember we accept insurance assignment as a courtesy to you. If your insurance company pays less than the estimated amount or does not pay within 60 days you will be billed for the balance.) I understand and give consent for treatment.

Insurance Information

If so, please complete the following...

Primary Insurance

Secondary Insurance

Finally, please let us know a little more about how you chose our office.

Please note, all forms are available on our website and in our office.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES and ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF ELECTRONIC DISCLOSURE OF PROTECTED HEALTH INFORMATION

Additional Forms/Authorizations

We would love to feature your before and after smile on our website.

I have had access to the Smiles by CDO Financial Policy form which includes authorization of direct payment of dental insurance benefits directly to the office of Smiles by CDO, Dr. Jarod Oliver.  I have also had access to the Smiles by CDO Consent for Internet Communications Form and give my consent regarding communications.