Patient Forms

Healthy Smiles Dental invites patients to download and complete these patient forms prior to their visit!

When you visit Healthy Smiles Dental, you will be asked to complete our patient forms. Please allow enough time to complete these before your appointment. As an added convenience, feel free download and complete these forms prior to your visit and bring them with you. Thank you for choosing Healthy Smiles Dental. We look forward to serving you!

  • Health History Information (Pg. 1-3)

  • Notice Of Privacy Policy (Please see separate document. This document does not need to be printed.
    Please read and sign the acknowledgement on pg. 4)

  • Financial Policy (pg. 5-6)

  • Records Request (pg. 7)


If you are an existing patient and you were instructed to fill out an updated health history please download and complete the following document:


*Please note that Dr. Kingston requires a completed health history update every two years

For any completed documents you may bring them to your appointment or send them via fax or email directly to our office.

Fax: 717-431-9731

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