Patient Forms


On behalf of our entire staff, we would like to welcome you to our practice! We take great pride in the quality of our work and facilities, so you receive the highest quality care available. Please be assured that we will do everything possible to make you feel comfortable and at ease.

Your initial visit with Dr. Dalessandro will include:

  • A review of your medical and dental history
  • A complete examination of your mouth and a review of your X-rays
  • An explanation of your periodontal problem
  • A treatment plan presented to you with the goal of bringing you back toward a more healthy periodontal condition

During this time, please ask questions so that may understand periodontal disease and its treatment better. Please note that if surgery is scheduled as part of your treatment plan, we ask for a surgery deposit in addition to the consultation fee.

In order to allow this appointment to proceed as smoothly as possible, we ask that you:

  • Complete the attached four forms and bring them to your appointment
  • Bring a photo ID and any additional materials your dentist may have given you
  • Bring an insurance form with the patient portion completed or a dental insurance identification card if you have dental benefits

For your convenience, a map with directions to our office can be found under the Contact Us section of our website. We look forward to meeting you and to working together to regain and maintain your oral health. 

  • Medical History [DOC] | [PDF]
  • Dental History [DOC] | [PDF]
  • Patient Information [DOC] | [PDF]
  • Consent Form [DOC] | [PDF]
  • Privacy Practices [DOC] | [PDF]

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