Patient Forms

If you are a new patient to our office, the attached file contains our new patient bundle with forms that will need to be filled out when you arrive at our office. Printing them, filling them out and bringing them with you will allow us to attend to your medical needs more quickly than completing them upon your arrival. Thank you and please call our office if you have any questions at all.

Patient Forms (Print & Complete All Forms Prior To First Office Visit)

Patient Medical History: MHpg1.pdf

Patient Medical History 2: Medical page 2.docx

HIPPA: Hipaa Disclosure consent.doc

Financial Policy: financial policy apple blossom.docx

Cancellation/No Show: cancellationandnoshow.docx

X-RAY Release Form: x-ray release form.doc

The following form only needs to be completed if a child will be brought to an appointment by someone other than a legal guardian that is at least 18 years of age:

Treatment without guardian consent form.docx

This web site uses files in Adobe Acrobat Portable Document Format (pdf) which require Adobe® Acrobat® Reader for viewing and printing. It is available to download free.

Testimonials

Dr. Ersan and her team are the best in the world in my opinion! I came to Apple Blossom with very serious tooth decay as I had been neglecting my teeth and avoiding going to the dentist and had major issues. They never judged me or tried to shame me like other dentists in the area had. They helped me to fix the problem in a very professional manner and I couldn't be happier with the results. Lilliannah, Dr. Ersan's dental assistant, was especially helpful and comforting through the whole process and they are all some of the nicest people you will meet!

Peter G. (Google)

Dr. Ersan is the best dentist I have experienced as an adult. I had work done (fillings) previously by a Dentist who cut a lot of corners and left me a bit anxious about dentistry in general. Dr. Ersan spent an hour with me, going over x-rays, explaining what had been previously done and what she planned to do to to keep my teeth healthy. She performed the cleaning herself and even prescribed toothpaste for my sensitive teeth. The rest of the staff were super pleasant and the office was incredibly clean and bright. Definitely have found my forever adult dentist.

Taylor K. (Google)