Dental Forms

This page contains information about our Patient Information and Medical History form.
Please read and know that you will be asked to provide this information before any services will be rendered.

After you have reviewed this information, you can print out a copy of the forms to fill out and bring with you to your first visit or you can mail them ahead of time.

Click on a link below:

Acknowledgement of Privacy Practices- PDF

Acknowledgement of Privacy Practices- DOC

Patient Information/Medical and Dental History- PDF

Patient Information/Medical and Dental History- DOC

Valley Dental Group Financial policy- PDF

Valley Dental Group Financial policy- DOC

Representation & Agreement Concerning Dental Charges- PDF

Representation and Agreement Concerning Dental Changes- DOC

Authorization for Use and Disclosure of Information- PDF

Authorization for Use and Disclosure of Information - DOC

Statement of Privacy Practices- PDF

Statements of Privacy Practices- DOC

***If you are having difficulty accessing or understanding any form pertaining to Valley Group Dental, please contact our office. We will be happy to assist with your specific needs.


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Please do not use this form to change or cancel appointments.

Our Values

  • We have a passion for what we do
  • Reasonable prices and financing options available
  • Committed to providing you with a positive dental experience
  • At the forefront of the latest dental procedures
  • Established in 1992