FDr. Francis Dental, P.C.Eric H. Francis, D.D.S. Pay Online (845) 226-7548

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Home/Patient Forms

Patient forms.

Forms for in-office visits and for nursing home patients and their families. Seven of our nursing home forms are fillable online — sign with your finger or mouse, submit electronically.

Nursing home forms FILLABLE

7 forms · for residents and family members

Patient Medical History

Comprehensive medical and dental history intake.

Fill out online →PDF

Extraction Consent

Informed consent for tooth extraction procedures.

Fill out online →PDF

Patient Appearance Approval

Aesthetic outcome approval for cosmetic and restorative work.

Fill out online →PDF

HIPAA Compliance Consent

Authorization for protected health information disclosure.

Fill out online →PDF

Informed Consent — Prophylaxis

Consent for routine cleaning and preventive procedures.

Fill out online →PDF

Self Pay / Billing Authorization

Billing authorization for patients without dental insurance.

Fill out online →PDF

Pay for Services Authorization

Family-member authorization to pay on resident's behalf.

Fill out online →PDF

In-office forms IN-OFFICE

5 forms · brought to your appointment

New Patient Registration

Demographics, emergency contact, and insurance information.

Medical & Dental History

Health background to inform your treatment plan.

Treatment Plan Acknowledgment

Review and sign-off on recommended care.

Financial Policy Agreement

Office payment policies and patient responsibilities.

Cancellation & No-Show Policy

Appointment scheduling expectations.

Submitted forms are routed to Info@DrFrancisDental.com and stored in HIPAA-compliant systems. Need help? Call (845) 226-7548 or email us directly.