Lexington, KY Family and Cosmetic Dentists, Dr. Larry Kopczyk, Dr. Brian Vieth, and Dr. Tim Majors.  Alumni Dental Center
New Patient Forms

formIf you would like to complete your registration form before you arrive, you may download it by clicking below. The new patient form is in PDF format. If you do not have Acrobat Reader, get a free copy by clicking on the link below. Also, after reading the Notice of Privacy Practices, print the Acknowledgement form below, sign it, and bring it in, too.

 

Adobe Reader
Adobe PDF Patient Registration Form (Adult) (Acrobat PDF form)
Adobe PDF Medical History (Adult) (Acrobat PDF form)
Adobe PDF Dental History (Adult) (Acrobat PDF form)
Adobe PDF Patient Registration Form (Child) (Acrobat PDF form)
Adobe PDF Dental and Medical History (Child) (Acrobat PDF form)
Adobe PDF Assignment of Benefits Form (Acrobat PDF form)
Adobe PDF Financial Policy (Acrobat PDF form)
Adobe PDF Records Release Form (Acrobat PDF form)
Notice of Privacy Practices (web page)
Acknowledgement of Receipt of Notice of Privacy Practices (web page)