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To fill out and save/send any of the PDF forms below, you will have to have Adobe Reader installed on your computer. It is available as a free download HERE


  1. Save the PDF form to your computer (don't just fill it out in your web browser window, as it may or may not save your changes)
  2. Locate the saved PDF document on your computer (usually in your Downloads folder, or on your desktop)
  3. Open the document using Adobe Reader
  4. Fill out the fields in the document, then save it
  5. You may email completed application to This e-mail address is being protected from spambots. You need JavaScript enabled to view it , or print it out and and bring it with you to your appointment


Patient Information Form (PDF)

Medical History Form (PDF)

Financial Agreement (PDF)

HIPAA Notice of Privacy Practices (PDF)

HIPAA Privacy Acknowledgement (PDF)


Evergreen Dental, SC - Appleton, WI

Evergreen Dental, SC

2310 E Evergreen Dr
Suite A
Appleton, WI 54913 View Map

(920) 734-0601

Office Hours

Mon - Thurs: 8am to 5pm
Fri: Closed

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Brands We Recommend

CrestG.U.M. Dental ProductsOral-B

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