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New Patient Forms


Dentist reviewing digital patient forms on a tablet with a patientThe following forms are provided to our patients online for download. Please print and complete the following prior to your new patient appointment with us!

•  Instruction for Forms
•  Medical History (Please fill out and sign bottom of page)
•  Dental Insurance Verification Form (Please fill out top of form)
•  Statement of Privacy Practices (Please fill out and sign 2nd page)

If you have questions about any of the paperwork, please give us a call at (513) 445-4282 and our staff will be happy to help you.
Four Locations to Serve You
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MASON
6410 Thornberry Court Suite C
Mason, OH 45040
ICO phone Martin 071318 (513) 445-4282
office@martinperio.com
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MIDDLETOWN
132 North Breiel Blvd
Middletown, OH 45042
ICO phone Martin 071318 513-424-4978
office@martinperio.com
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FAIRFIELD
1211 Nilles Road
Fairfield, OH 45014
ICO phone Martin 071318 513-829-8999
office@martinperio.com
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OXFORD
5279 Morning Sun Rd
Oxford, OH 45056
ICO phone Martin 071318 513-523-5064
office@martinperio.com
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