Ashland City Dental
James Fleenor DMD
Creating Beautiful Smiles
Call: (615) 235-5144

Patient Forms

If you are a new patient to our office, the attached file contains our new patient bundle with forms that will need to be filled out when you arrive at our office. Printing them, filling them out and bringing them with you will allow us to attend to your medical needs more quickly than completing them on your arrival.  Thank you and please call our office if you have any questions at all.

Patient Forms

Patient Registration

Medical History

Financial and Office Policies

Electronic Consent

HIPAA Informed Consent Authorization

Acknowledgement of HIPAA and Privacy Practices

Notice of Privacy Practices

Patient Screening Form-Covid 19

(Print & Complete All Forms Prior To First Office Visit) 

 

 This web site uses files in Adobe Acrobat Portable Document Format  (pdf) which require Adobe® Acrobat® Reader for viewing and printing. It is available to download free.

Contact Us

We encourage you to contact us with any questions or comments you may have. Please call our office or use the quick contact form below.

Office Location

  • Ashland City
  • 189 Monroe Place
  • Suite 104
  • Ashland City, Tennessee
  • 37015
  • Map & Directions
  • Call: (615) 235-5144