Patient Forms 2018-08-31T12:22:22+00:00

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.

New Patient Registration Form

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New Patient Medical History

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Patient Record Release Form

(if you want to have dental records sent to us from a previous dentist)

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HIPAA Privacy Act Form

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HIPAA Personal Representative Form

(if you are over age 18 and want to have someone be able to have access to your account and schedule on your behalf)

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Dental $avings Plan

Dr. Wyne wanted to help individuals who are uninsured. The Dental $avings Plan is for patients with no insurance who want/ need dental care. The D$P is not an insurance plan, but an in-house discount plan that is specific to Richard G. Wyne, DDS and can only be utilized in this practice.  For more details, please click on the links below:

Apply online!

Apply Here

D$P Application

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D$P Brochure

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