Patient Forms


Our office welcomes patients of all ages, stages, and dental care needs. We would be delighted to welcome you and your family into our practice and hope you will find your dental home with us. 

To help you prepare for your first appointment in our office, you can find all the new patient forms below. Please print and complete the appropriate forms to bring with you to your appointment.  

No printer? No problem! Most of our forms are now also available online! Click below to fill out our online forms. 

*The tongue/lip tie evaluation and ALF evaluation forms are not currently available to complete online. You are welcome to print the form ahead of time or plan to arrive a few minutes early for your appointment to complete the form in our office. 

If you have any questions about the forms or your upcoming appointment, please call us to speak with one of our friendly staff members. 740-369-4550 

We look forward to seeing your smile!

New Patient Information (for ALL New Patients)
Start These Forms
 Infant Tongue/Lip Tie  Questionnaire (For Infants to Age 2)
Print This Form
Advanced Lightwire Functional Appliance Evaluation (For ALF Consultations only)
Print This Form
Tongue/Lip Tie Oral Function Questionnaire (For Children and Adults Age 2 and Older)
Print This Form

Rebecca Jordan Family Dentistry

665 W Central Ave, Delaware, Delaware, OH 43015

Phone: (740) 369-4550


MON - TUE : 8:00 am - 4:00 pm

WED : 8:00 am - 2:00 pm

THU : 8:00 am - 4:00 pm

FRI - SUN : Closed

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