Mauldin Family Dentistry
Dr. Daniel J. Halasz
Creating Beautiful Smiles

Patient Forms


We look forward to meeting you in person at your first appointment.  If you have not already made an appointment, and would like to, please submit a request or call our office today.

Before you come in, we thought you might appreciate some information about our practice and what to expect during your visit.  We may be a little different than dentists you've had in the past. We believe that achieving and maintaining healthy teeth and gums takes a team effort and that you play as big a role as we do in reaching that mutual goal. So, you can expect to be extensively involved in your treatment program.   

Below, you will find our New Patient Forms, which will provide our office with basic information about you.  This includes details on any Dental Insurance plan(s) you may have, as well as your medical history, which is vital in developing your treatment plan. These forms may be filled out at your first appointment with us; however, printing them, filling them out and bringing them with you will allow us to attend to your dental needs more quickly than completing them on your arrival.  Please also remember to bring your dental insurance card, as well as a current Picture I.D.

If you have dental insurance, we will file any charges incurred during your visit with them, and any uncovered charges will be balance-billed to the responsible party on your account.  If you do not have dental insurance, we ask that you pay for services in full on the day of your appointment in form of cash or check (we also accept VISA, MasterCard, Discover and CareCredit). For more information on our Financial Policy, please reference our Financial Policy document below.

If you have any questions, please call us at any time. We welcome you to our practice and look forward to meeting you soon!



Patient Information Form

Patient Medical History Form

Notice of Privacy Practices (HIPPA)

Acknowledgement of Receipt of Privacy Practices Form (HIPPA)

Mauldin Family Dentistry Financial Policy

Click here to Email Forms

 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.


View More