Patient Form

Save time when you come in for your appointment by filling out the following form or downloading and printing the form here.

Patient Information

Prefix
Gender
Address

Referral Information

Responsible Party Information

Gender
Relationship to patient
Address

Dental Insurance Information

Name of Insured
Is insured a patient?
Relationship to insured
Insurance Address

Health Information

Please check if taking any of the following:
Medical Conditions (Past or Present)
Hepatitis
Allergies
Have you been examined by a dentist in the last year?
Do you grind your teeth?
Do you like the color of your teeth?
Do you drink carbonated beverages?
Do you smoke/or use any other tobacco products?
Have you had radiation treatment in head/neck area?
Have you been advised to be premedicated with antibiotic prior to dental work?
Would you like to talk about being sedated to relieve anxiety prior to dental work?

Contact us

  • Mon & Wed 7am - 3pm
  • Tue & Thu 8am - 5pm
  • Friday by appointment only
  • 6930 Fern Avenue # 100
  • Shreveport, LA 71105
  • info@hermesandhayniedds.com
  • (318) 797-9997