Patient Forms

Please take a minute to print and fill out the patient information form before your first appointment:

  • Health History (English) PDF
  • Historia médica (Español) PDF
  • Patient Registration PDF
  • Notice of Privacy Practices PDF
  • Attention Female Patient PDF
  • Medical Release PDF
  • Pulpotomy of Primary Teeth Consent PDF
  • Root Canal Treament Consent PDF
  • Flipper Consent PDF
  • Invisalign / Orthodontic Constent PDF
  • How to Care For Your Braces PDF
  • Cómo Cuidar De Sus Apoyos (Español) PDF
  • Post-Op Instructions for Extractions PDF
  • Retainer Contract PDF
  • Photo/Facebook Consent PDF
  • Ortho Diagnosis Card PDF

If you're unable to open PDF files, you can get Adobe Reader® for free.

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Call: (475) 282-4551

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12 Month Smiles
(475) 282-4551
Office Hours
  • Tuesday: 9am-6pm
  • Wednesday: 3pm-6pm
  • Friday: 9am-5pm
  • Saturday: 9am-1pm
12 Month Smiles
East Haven
(203) 469-5644
Office Hours
  • Monday-Thursday: 9am-6pm
  • Friday: 8am-4pm
  • Saturday: 8am-1pm