(703) 689-4442
Reston, VA

Patient Forms and Information

Below are some of the forms we use in our office for new and existing patients. We supply each as reference so that patients may be prepared for their appointment when they visit our office. If you so choose, you may print and complete the forms in advance to help expedite your appointment time.

You can Fax them in advance to 703-689-0859.


New Patient Registration Form

Basic registration form for new patients.


New Patient Health History Form

A complete profile of your medical and dental health history so we are prepared to give you the best and most effective treatment possible.


Sedation Instructions & Consent Form

A breakdown of the instructions for before and after IV sedation is used for your appointment.


Understanding Insurance / Financial Policy

An overview of what insurance means to your dental care.


Patient Release

Patient Authorization to Release Records to Dr. Charles Fields.