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2337 G St, Suite 3 dot Belleville, KS dot 66935 dot 785-527-5602




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For each new patient who comes to our office, a new patient chart is created. Several forms must be fill out or read and signed that are put in that chart. To aid in you completing these forms we have included some of the forms on our website to give you time to fill them out at home at your leisure. Simply print a copy of each form for each family member who is coming in for the first time. Fill them out and bring them with you to your first appointment. Also make notes of any questions you have from these forms for the receptionist when you come in.

Patient Information / Dental-Medical History / Dental-Medical History (back side)

General Consent

These are not the only forms that may need to be signed, depending on whether the patient is a child or adult and dental treatment that is needed, but the few remaining forms are much simpler and can be done here in the office.

You will also be asked to update your medical history yearly when you come in for a dental procedure.

We welcome you to Fischer Family Dentistry and look forward to many years of assisting you with your dental care.


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