Patient Information

Patient Forms

At Lacey-Antholz-Donner Dentists P.C., we will collect a complete record of your health information to ensure the best management of your dental health. Please click on the forms below. Having these forms filled out prior to your dental appointment and can help you save time the day of your appointment and so that we may update your records.

COVID‐19 PANDEMIC PATIENT DISCLOSURES FORM

NEW PATIENT FORM
Download our new patient form, print off, complete, and bring to your appointment.

 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Please assist us by providing the following information at the time of your visit:
any current x-rays, list of medications, dental insurance information,
or any need for antibiotic pre-medication.

Please click here to download adobe reader so that you may access the above forms.

Change of Appointment

Please allow a minimum of 24 hours notice to change or cancel your appointment. Shorter notice will severely limit our ability to offer another patient their most preferred time.

FINANCIAL INFORMATION

Our office accepts all traditional forms of insurance. We will be happy to file claims as a courtesy for our patients. However, we do expect necessary co-payments and deductibles to be paid at the time of service.

CASH DISCOUNT

We are happy to offer a discount for our patients who pay in full with cash or check on the date of service.

CREDIT CARDS

We accept Visa, MasterCard, and Discover

CARE CREDIT

We are pleased to offer our patients a personal line of credit for treatments and procedures.
What is Care Credit?