Patient Information

New Patient Forms

Please download and fill out the forms below and bring them with you to your first visit.

Patient Information

Medical History

List of Medications

Financial Agreement

Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

HIPAA Compliance Patient Consent Form

Free Acrobat Reader is needed to view the forms. You can download it here.

Insurance Information

Erbeck Family Dental accepts most insurances. Please contact us so we can look up your specific plan and better inform you of your coverage and benefits.

Types of Payment Accepted

We accept cash, checks, and all major credit cards.

Call us at (513) 398-7051 or schedule an appointment online
We look forward to giving you a healthy smile!