Patient Forms

We're delighted to welcome you to our practice and pleased that you have chosen us to serve your dental needs.  We are serious about providing superior dental care for our patients.  Our goal is to help you feel and look your very best through excellent dental care.

For your first visit to our practice, we request that you complete the following patient forms to facilitate being seen as soon as possible.  Please print and complete all of our Patient Information forms listed below before your arrival.  Remember to bring them with you at the time of your appointment or mail the completed forms back to our office as soon as possible. 

Thank you for choosing St. Mary Dental for your prosthodontic needs.  We look forward to seeing you soon.


Dr. Saeda Basta & St. Mary Dental Team

Please remember to bring any insurance cards and/or information (Medical or Dental) that might apply to you when you visit us. 

1. New Patient Information.pdf
2. Appointment and Financial Information.pdf
3. Health History Questionnaire.pdf
4. Notice of Privacy Practices.pdf
5. Pt acknowledgement of Privacy Practices.pdf
6. Dental Material Fact Sheet and Acknowledgement.pdf
7. Patient Insurance Authorization.pdf  Only complete if you have dental insurance that you would like to utilize. 

 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 welcome the opportunity to answer questions regarding services we provide. Please call our office or use the contact form below.


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