Patient Forms

NEW PATIENTS

Our office is always welcome to new patients of all ages, stages and dental care needs. We will 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 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. If you are coming for this type of appointment, you will still need to print the questionnaire based on your child's age and appointment type, either by printing or when you arrive to the 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, D.D.S

665 W Central Ave, Delaware, Delaware, OH 43015

Phone: (740) 369-4550

Email: [email protected]

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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