Patient Forms

Patient Information [Child]

  • Parent/Guardian Information

  • Emergency Contact

  • Insurance Information

  • Dental History

  • Medical History

  • Authorization

    I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.

Contact info

1795 Penfield Rd.
Penfield, NY 14526

Opening hours

Monday:               8 a.m. – 2 p.m.
Tuesday:              8 a.m. – 5 p.m.
Wednesday:        10 a.m. – 7 p.m.
Thursday:             closed
Friday:                  8 a.m. – 5 p.m.
Saturday:              8 a.m. – 1 p.m.

Our Location