(812) 288-4691

fax (812) 288-7178

409 6th St, Jeffersonville, IN 47130, USA

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WE ARE ALWAYS ACCEPTING NEW PATIENTS

The first step is to call our office to set up an appointment. For your convenience please, print and fill out these forms to bring to your initial appointment or send to us beforehand via fax/email to save time during your first appointment. If you have multiple family members visiting, please fill out one form for each. Thank you!

You can view a Privacy Practices Act from the link below before completing the HIPAA form if you prefer!

Fax: (812) 288-7178

Email: staff@brinegardentistry.com

NEW PATIENT INFORMATION FORM

MEDICAL HISTORY FORM

HIPAA FORM

RECORD RELEASE FORM