Online Forms

We now offer our patients a convenient option to fill out all of their new patient forms online. No need to print or handwrite anything. Use our secure online platform to fill out all of your required patient paperwork.

Follow the links below to fill out your new patient forms on our online platform.

• New Patient Intake Forms
• Notice of Privacy Practices
• Cosmetic Questionnaire

Printable Option

Step 1
Download and complete the following forms:

(All forms require your computer to run Adobe.  If you do not have Adobe installed, please click here).

New Patient Forms

• Patient Info
• Dental Health Questions
• Medical History
• Financial Policy
• Jacob Grapevine, DDS Consent
• Notice of Privacy Practice
• Acknowledgment of Receipt
• Appointment Cancellation Policy

For our TMD patients, In addition to the new patient forms please fill out the appropriate forms below for your examination.

New Patient TMD Forms

• New Patient Questionnaire for TMD Issues (Please fill out the 3 page form and return to our office before your appointment in order for us to be prepared for your visit.  Thank you.)
• TMJ Screening Form – This 1 page TMJ screening form is used for patients who are wondering if they have an issue related to TMJ. Please contact the office if you have questions.

Step 2
Send the form back to our office 24 hours before your appointment by:

Fax:
972.964.2387

Mail:
2101 Teakwood Lane Suite 400
Plano, TX 75075