New Patients

Please complete the form below prior to your first visit, this will save you needing to come in 15 minutes early to complete the forms before your first appointment.

If you have dental insurance, please bring in your carrier information on the day of your appointment.

Patient Information
The primary contact person must not currently live with you.
Do you have any of the following conditions?
Medical History

Heads up! Please fix the form errors and submit again.

Disclaimer

  • I understand that I am responsible to clear my account if my insurance company has not paid it within 60 days.
  • I agree with the Recall/Confirmation policy.
  • By providing my e-mail address, I authorize Dr. Kenneth P. Lawrence Inc. to send messages regarding when myself or any of my family members are due for recall exams, appointment reminders or receiving statements on my account.
  • I authorize the use of any photos taken of me at this office to be used for educational purposes, case presentations or promotions with the condition that all identifying factors are removed.
  • I authorize the dental personnel to perform services for the preventions and treatment of dental disease using the appropriate procedures and medications and assume the responsibility for the fees associated with the procedures.
  • I understand and agree to all the above statements.