Patient Forms

New patient? Please download and fill out the following forms and bring with you when you come in for your first appointment.

Patient Medical History Form

This form is mandatory for new patients. To expedite your visit, print this form, fill it out and bring it with you for your first visit.

Patient Medical History Form
Patient Medical History form.pdf
Adobe Acrobat document [198.4 KB]

Current Medication Form

This form is for patients that have a list of medication that will not fit on the health history form

1 Medication sheet.pdf
Adobe Acrobat document [16.5 KB]
PATIENT RESPONSIBILITY AGREEMENT.pdf
Adobe Acrobat document [16.0 KB]

Privacy Notice

Please read over and sign our Notice of Privacy Practices, acknowledging our privacy policy. This form should also be brought to your first appointment.

Privacy Notice
Hippa information.pdf
Adobe Acrobat document [32.8 KB]
Hippa consent.pdf
Adobe Acrobat document [13.3 KB]

In order to view or print these forms you will need Adobe Reader installed www.get.adobe.com/reader/

Make an Appointment Today!

Call us at: 517 4234700

 

Scott Doman D.D.S.

102 S Pearl St

Tecumseh, MI 49286

Fax: 517 4239741

Email: scottdomandds@gmail.com

 

Use our contact form to get in touch.

Office Hours

Monday - Friday 7:00am - 5:00pm by appointment

 

Early morning appointments are available for your convenience.

 

Outside our regular business hours, please note our emergency care information.

Keep Your Teeth Healthy!

What is the best preventive care for your teeth? Find out how to make your next visit easier and more pleasant.

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