Patient Online Forms

The following forms are available for your convenience. To expedite your first check in procedure, please fill these forms out and bring them with you to your first appointment or email them directly.

***Note: To open the files below you may do the following: Click the link to open up the document in a browser window (if you get a user login and password screen, please ignore it by hitting cancel. The document will still open); or you may also download the file by right-clicking the link, then saving the target source to your hard drive. Just note the location you saved the file for future reference.

Adult Patient Care Forms

These forms are to be filled out in its entirety for adults ages 18 and up.
- Dental/Medical History (fillable pdf)

Child Patient Care Forms

These forms are to be filled out in its entirety for children ages 3-17.
- Dental/Medical History Page 1 (fillable pdf)
- Dental/Medical History Page 2 (fillable pdf)

Consent For Use and Disclosure of Health Information

By signing these forms, you will consent to our use and disclosure of your protected health information (PHI) to carry out treatment, payment activities and healthcare operations.
- Consent for Use (pdf)
- Disclosure of Health Information (pdf)

Acknowledgement of Receipt for Notice of Privacy Practices

To obtain acknowledgement of receipt of our notice of privacy practices.
- Acknowledgement of Receipt (pdf)

Why choose LWSS?

Experienced Staff

We have served the area for decades and grown by having the best staff of professionals in our practices.

Multiple Locations

6 locations for your convenience with multiple services at several practices

Pro-Scheduling

We work hard on scheduling to minimize the time you spend waiting and making your visit pleasant.

LWSS Dental Plan

We offer an affordable, yearly dental care plan for those without insurance.