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Patient Center › Patient Forms

New & Existing Patient Forms

Please fill in your forms before your appointment so your visit is easier. You will sign the forms electronically when you are here at our office.

New Patient Forms

First time with us? Complete your registration, financial agreement, HIPAA and medical history forms online before your visit.

Fill out new patient forms

Existing Patient Forms

Already a patient? Update your details, insurance and medical history through our secure patient portal.

Open existing patient forms

What each form covers

Patient Registration Form

Your contact details, responsible party and insurance information.

Open this form

Patient Financial Agreement

How payment, insurance benefits and financing arrangements are handled.

Open this form

HIPAA

Notice of privacy practices and your acknowledgement of receipt.

Open this form

Medical History Form

Conditions, allergies and current medications so treatment can be planned safely.

Open this form

Questions before your first visit?

Call us at (904) 272-7277 or email info@jaxcosmeticdentist.com and our team will help.

Request an appointmentInsurance & financing