New Patient Form & Specials | Chillicothe Family Dental

Welcome to Chillicothe Family Dental

We’re so glad you’ve chosen us for your care! To help us provide the best experience, please complete this form to move forward in our New Patient Onboarding process.

All submissions are secure and HIPAA compliant — your information is protected.

Thank you for helping us make your first visit smooth and efficient. We look forward to meeting you soon!

New Patient Insurance Information

First Name:

Last Name:

Date of Birth:

Mobile Phone Number:

Preferred Contact Method:

Email:

Free Text

*We suggest text so you are able to communicate with the office through our secure texting line.

Street Address:

Apt, unit, etc...

City

State

Zip Code:

Appointment Info

Appointment Notes

(For admin team: copy/paste into chart notes when adding new patient)

Free Text

Appointment Request Details

Type of Appointment:

If Other please state:

Approximate Date of Last Dental Exam:

Are you experiencing pain?

Are you experiencing swelling?

Message for the office:

Free Text

Insurance Information

Please fill out the following information to move forward in our New Patient onboarding process. If you plan to be Self-Pay, Out of Network or are interested in our Membership plan, we are still happy to see you at our practice.

Do you plan to use insurance for this visit?

Free Text

*If yes is mandatory fill out the info below

Insurance Company:

Other:

Free Text

*If other, please reach out to your insurance company and ask about your benefits with Chillicothe Family Dental.

Current Group Number:

Subscriber Name:

Subscriber Date of Birth:

Subscriber ID #:

Insurance Phone Number:

Subscriber Employer:

Is there anything else we need to know before scheduling your visit?

Opt-In

By submitting this form and signing up for texts, you consent to receive text messages from Chillicothe Family Dental at the number provided, including messages sent by autodialer. Consent is not a condition of purchase. Msg &

data rates may apply. Msg frequency varies. Unsubscribe at any time by replying STOP or clicking the unsubscribe link. Reply HELP for help.

Privacy Policy & Terms.

Opt-In

I understand that this form is a request only and the practice will reach out to confirm my appointment. All information is transmitted securely in compliance with HIPAA privacy standards.

Insurance Information

Please fill out the following information to move forward in our New Patient onboarding process. If you plan to be Self-Pay, Out of Network or are interested in our Membership plan, we are still happy to see you at our practice.

Old Request Appointment

New Patient Insurance Information old

Do you plan to use insurance for this visit?

Free Text

*If yes is mandatory fill out the info below

Insurance Company:

Other

Free Text

*If other, please reach out to your insurance company and ask about your benefits with Chillicothe Family Dental.

Current Group Number:

Subscriber Name

Subscriber Date of Birth:

Subscriber ID #

Insurance Phone Number

Subscriber Employer:

Is there anything else we need to know before scheduling your visit?

Opt-In

I understand that this form is a request only and the practice will reach out to confirm my appointment. All information is transmitted securely in compliance with HIPAA privacy standards.

Opt-In

By submitting this form and signing up for texts, you consent to receive text messages from Chillicothe Family Dental at the number provided, including messages sent by autodialer. Consent is not a condition of purchase. Msg &

data rates may apply. Msg frequency varies. Unsubscribe at any time by replying STOP or clicking the unsubscribe link. Reply HELP for help.

Privacy Policy & Terms.

Limited-Time Promotions

New Patient Special

Teeth Whitening Promo

Refer a Friend & Earn Rewards

Why Choose Us

Affordable Dental Care, No Insurance Needed

$59 /month

$79 /month

Welcome to Chillicothe Family Dental

New Patient Insurance Information

Insurance Information

Old Request Appointment

New Patient Insurance Information old

Limited-Time Promotions

New Patient Special

Teeth Whitening Promo

Refer a Friend & Earn Rewards

Why Choose Us

Affordable Dental Care, No Insurance Needed

$59 /month

$79 /month

Welcome to Chillicothe Family Dental

New Patient Insurance Information

Insurance Information

Old Request Appointment

New Patient Insurance Information old

Affordable Dental Care, No Insurance Needed