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New Patients Forms & Great Offers

Samuels Dental Arts in Gettysburg PA

We're happy to have you! Here's all the information you'll need.

request an appointment

Please print and fill out each one of the listed forms and bring it to your initial appointment.

The following forms are PDFs and can be viewed and printed using Adobe Reader.

Comfort Menu

Consent for Treatment of a Minor (for under 18 only)

Health History

Privacy Practices, Permission to Release Information, and Consent to Discuss Treatment

HIPAA

Patient Information

Epworth Sleepiness Scale

Office Financial Arrangements and Cancellation Policy

Print All

New Patients Offers

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Call for your appointment and more details. Cash only. Offers good for 60 days from date of receipt. New Patients only, except as noted.*Not valid with any other offer. Not combinable with insurance.*
New call-to-action
Call for your appointment and more details. Cash only. Offers good for 60 days from date of receipt. New Patients only, except as noted.*Not valid with any other offer. Not combinable with insurance.*
New call-to-action
Call for your appointment and more details. Cash only. Offers good for 60 days from date of receipt. New Patients only, except as noted.*Not valid with any other offer. Not combinable with insurance.*
New call-to-action
Call for your appointment and more details. Cash only. Offers good for 60 days from date of receipt. New Patients only, except as noted.*Not valid with any other offer. Not combinable with insurance.*
New call-to-action
Call for your appointment and more details. Cash only. Offers good for 60 days from date of receipt. New Patients only, except as noted.*Not valid with any other offer. Not combinable with insurance.*
New call-to-action
Call for your appointment and more details. Cash only. Offers good for 60 days from date of receipt. New Patients only, except as noted.*Not valid with any other offer. Not combinable with insurance.*

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