Patient Forms

Things to bring to your first visit:

ID Card, Insurance Card, Completed Forms (either online or printed), Preferred method of Payment

Please take a few moments to fill out the forms below prior to your first visit:

Fillable Online Forms For First Visit

Printable Forms

  • Patient Registration PDF | DOC
  • Medical History         PDF | DOC
  • HIPAA Release        PDF
  • HIPAA Information   PDF   
  • Parent/Guardian Consent to Treat Minor​  PDF | WebForm

Release Form for Transferring Records

HIPAA Release Form

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Eastern Carolina Dental
200 Doctors Dr F., Jacksonville, NC 28546
(910) 353-4242