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 PDFNew Patient Registration Packet (18 and older)
Adobe PDFNew Patient Registration Packet (14 and 17)
Adobe PDFNew Patient Registration Packet (13 and younger)

Adobe PDFExisting Patient Medical Update (14 and older)

Adobe PDFExisting Patient Medical Update (13 and younger)
Adobe PDF Records Release Form
Notice of Privacy Practices (web page)
Acknowledgement of Receipt of Notice of Privacy Practices (web page)