New Patients
Fill out the New Patient Consent Form Online

In order to become a new patient, a New Patient Consent Form must filled out at least 1 business day prior to the scheduled visit. We have provided you the capability to securely fill out the form online through DocuSign (HIPAA compliant online signature partner). 

 

 

If you are having any issues whatsoever filling out or viewing this form, please call us at (816) 548-1270. We would welcome the opportunity to walk you through the process. The form is comprehensive in nature and should take about 15 minutes to fill out if you have all the required patient health information readily available.

New Patient Forms / Disclosures

Dental services provided by Rita M Burnett DDS Mobile LLC