Thank you for your interest in becoming a new patient!
Our providers and staff work hard to provide the most compassionate and individualized treatment to our patients. In order to begin the referral process, please complete our online form below or contact us for more information.
Medicaid Waiver Patients
If a patient has a legal conservator, the consent forms will need to be signed by the conservator. If a patient is under 18, the consent forms will need to be signed by the patient’s legal guardian.
Please download and complete each document.
- Medicaid Waiver Form
- Consent for Sedation and Treatment
- Consent for Treatment
- Notice of Privacy Practices
- Acknowledgment of Privacy Practices
- Consent for Records Release
- Title VI *
*The Title VI form is only necessary for patients who are part of the Medicaid Waiver.
Once completed, the information may be submitted via e-mail to email@example.com or fax to 615-915-6091. We will be in touch after the new patient information is received and reviewed. If you have any questions at all about becoming a new patient or about the referral process, you may contact our intake coordinator, Chelsea Bailey.
Click here to learn more about the services we offer. We look forward to meeting you and thank you for the opportunity to provide excellent dental care for you or your loved one.