Forms - Fairfax, VA

For your convenience

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dental patient filling out forms

For New Patients

The referral form below is provided for our referring doctors. For your convenience, this form can be printed, filled out and given to the patient or mailed to our office prior to the patient’s first visit with us. Thank you for your referrals and your expression of confidence in our office.
Patient Registration And Health History Form
Notice of Privacy Practices
Acknowledgement of Receipt of NPP

For Referring Doctors

The referral form below is provided for our referring doctors. For your convenience, this form can be printed, filled out and given to the patient or mailed to our office prior to the patient’s first visit with us. Thank you for your referrals and your expression of confidence in our office.
Doctor Referral Form

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Dr. Withers is a Periodontist in Fairfax, VA. Dr. Withers and his team are here to serve you and meet your dental needs as comfortably as possible. It is our goal to make your experience in our Fairfax VA Dental office a pleasant visit and restore your dental health quickly and professionally.

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