{"id":1576,"date":"2021-02-17T13:21:12","date_gmt":"2021-02-17T18:21:12","guid":{"rendered":"http:\/\/box5730.temp.domains\/~fortwbb5\/?page_id=1576"},"modified":"2025-10-23T10:40:31","modified_gmt":"2025-10-23T14:40:31","slug":"patient-forms","status":"publish","type":"page","link":"https:\/\/fortwaynedentalgroup.com\/?page_id=1576","title":{"rendered":"Patient Forms"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1216.8px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_3_5 3_5 fusion-flex-column\" style=\"--awb-padding-bottom:13px;--awb-bg-color:#f4f4f4;--awb-bg-color-hover:#f4f4f4;--awb-bg-size:cover;--awb-width-large:60%;--awb-margin-top-large:0px;--awb-spacing-right-large:3.2%;--awb-margin-bottom-large:36px;--awb-spacing-left-large:3.2%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><a class=\"fb-icon-element-1 fb-icon-element fontawesome-icon fa-address-card fas circle-yes fusion-link\" style=\"--awb-iconcolor:#3bafbf;--awb-iconcolor-hover:#3bafbf;--awb-circlecolor:#f4f4f4;--awb-circlecolor-hover:#f4f4f4;--awb-circlebordercolor:#f4f4f4;--awb-circlebordercolor-hover:#f4f4f4;--awb-circlebordersize:1px;--awb-font-size:93.28px;--awb-width:186.56px;--awb-height:186.56px;--awb-line-height:184.56px;--awb-margin-top:0;--awb-margin-right:0;--awb-margin-bottom:0;--awb-margin-left:0;--awb-align-self:center;\" href=\"https:\/\/pdf.ac\/2UQjD1\" target=\"_self\" aria-label=\"Link to https:\/\/pdf.ac\/2UQjD1\"><\/a><div class=\"fusion-text fusion-text-1\"><h2 style=\"text-align: center; --fontsize: 46; line-height: 1.25; font-family: ABeeZee; font-weight: 400;\" data-fontsize=\"46\" data-lineheight=\"57.5px\" data-fusion-font=\"true\" data-fusion-google-font=\"ABeeZee\" data-fusion-google-variant=\"400\">New Patient Application<\/h2>\n<p style=\"text-align: center;\">Looking for experienced care from our team?<br \/>\nWe&#8217;d love to create the perfect treatment plan for you!<br \/>\nPlease fill out this form today!<\/p>\n<\/div><div style=\"text-align:center;\"><a class=\"fusion-button button-flat fusion-button-default-size button-default fusion-button-default button-1 fusion-button-span-no fusion-button-default-type\" style=\"--awb-margin-top:15px;\" target=\"_self\" href=\"https:\/\/pdf.ac\/2nqMFXMBL\"><span class=\"fusion-button-text awb-button__text awb-button__text--default\">Fill Out online<\/span><\/a><\/div><div style=\"text-align:center;\"><a class=\"fusion-button button-flat fusion-button-default-size button-default fusion-button-default button-2 fusion-button-span-no fusion-button-default-type\" style=\"--awb-margin-top:25px;--awb-margin-bottom:25px;\" target=\"_self\" href=\"https:\/\/fortwaynedentalgroup.com\/wp-content\/uploads\/2023\/09\/New-Patient-Application-_with-NEW-HIPPA-Forms_.pdf\"><span class=\"fusion-button-text awb-button__text awb-button__text--default\">Print and fill out<\/span><\/a><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_2_5 2_5 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:40%;--awb-margin-top-large:0px;--awb-spacing-right-large:4.8%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:4.8%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-image-element \" style=\"--awb-caption-title-font-family:var(--h2_typography-font-family);--awb-caption-title-font-weight:var(--h2_typography-font-weight);--awb-caption-title-font-style:var(--h2_typography-font-style);--awb-caption-title-size:var(--h2_typography-font-size);--awb-caption-title-transform:var(--h2_typography-text-transform);--awb-caption-title-line-height:var(--h2_typography-line-height);--awb-caption-title-letter-spacing:var(--h2_typography-letter-spacing);\"><span class=\" fusion-imageframe imageframe-none imageframe-1 hover-type-none\"><img decoding=\"async\" width=\"720\" height=\"960\" title=\"95015471_10157425053951492_7715641321125314560_n\" src=\"https:\/\/fortwaynedentalgroup.com\/wp-content\/uploads\/2021\/02\/95015471_10157425053951492_7715641321125314560_n.jpg\" alt class=\"img-responsive wp-image-1402\" srcset=\"https:\/\/fortwaynedentalgroup.com\/wp-content\/uploads\/2021\/02\/95015471_10157425053951492_7715641321125314560_n-200x267.jpg 200w, https:\/\/fortwaynedentalgroup.com\/wp-content\/uploads\/2021\/02\/95015471_10157425053951492_7715641321125314560_n-400x533.jpg 400w, https:\/\/fortwaynedentalgroup.com\/wp-content\/uploads\/2021\/02\/95015471_10157425053951492_7715641321125314560_n-600x800.jpg 600w, https:\/\/fortwaynedentalgroup.com\/wp-content\/uploads\/2021\/02\/95015471_10157425053951492_7715641321125314560_n.jpg 720w\" sizes=\"(max-width: 1024px) 100vw, (max-width: 640px) 100vw, 600px\" \/><\/span><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-flex-container fusion-parallax-none nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--link_hover_color: #ffffff;--awb-border-sizes-top:0px;--awb-border-sizes-bottom:0px;--awb-border-sizes-left:0px;--awb-border-sizes-right:0px;--awb-border-color:#f4f4f4;--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:36px;--awb-padding-bottom:0px;--awb-padding-top-small:48px;--awb-margin-top:0px;--awb-margin-bottom:0px;--awb-background-color:#f4f4f4;--awb-background-image:url(&quot;http:\/\/www.fortwaynedentalgroup.com\/wp-content\/uploads\/2015\/12\/rgb-gradient-bar-for-logo-carrasel.jpg&quot;);--awb-background-size:cover;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:calc( 1170px + 0px );margin-left: calc(-0px \/ 2 );margin-right: calc(-0px \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-padding-bottom:-2px;--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:1px;--awb-spacing-right-large:0px;--awb-margin-bottom-large:-2px;--awb-spacing-left-large:0px;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:0px;--awb-spacing-left-medium:0px;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:0px;--awb-spacing-left-small:0px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-1 fusion-sep-none fusion-title-center fusion-title-text fusion-title-size-two\" style=\"--awb-text-color:rgba(255,255,255,0.77);--awb-margin-top:14px;--awb-margin-bottom:24px;--awb-margin-top-small:0px;--awb-margin-right-small:0px;--awb-margin-bottom-small:20px;--awb-margin-left-small:0px;--awb-font-size:50px;\"><h2 class=\"fusion-title-heading title-heading-center fusion-responsive-typography-calculated\" style=\"margin:0;font-size:1em;--fontSize:50;line-height:1.25;\"><span data-fusion-font=\"true\" data-fusion-google-font=\"ABeeZee\" data-fusion-google-variant=\"400\" style=\"font-family: ABeeZee; font-weight: 400;\">Trusted Partners<\/span><\/h2><\/div><div class=\"fusion-image-carousel fusion-image-carousel-auto fusion-image-carousel-1\"><div class=\"awb-carousel awb-swiper awb-swiper-carousel awb-carousel--carousel awb-swiper-dots-position-bottom\" data-layout=\"carousel\" data-autoplay=\"yes\" data-autoplayspeed=\"2500\" data-autoplaypause=\"no\" data-loop=\"yes\" data-columns=\"4\" data-columnsmedium=\"1\" data-columnssmall=\"1\" data-itemmargin=\"95\" data-itemwidth=\"180\" data-touchscroll=\"drag\" data-freemode=\"no\" data-imagesize=\"auto\" data-scrollitems=\"1\" data-centeredslides=\"no\" data-rotationangle=\"50\" data-depth=\"100\" data-speed=\"500\" data-shadow=\"no\" data-pagination=\"bullets\" style=\"--awb-columns:4;--awb-column-spacing:95px;\"><div class=\"swiper-wrapper awb-image-carousel-wrapper fusion-flex-align-items-center\"><div class=\"swiper-slide\"><div class=\"fusion-carousel-item-wrapper\"><div class=\"fusion-image-wrapper hover-type-none\"><img decoding=\"async\" width=\"512\" height=\"161\" src=\"https:\/\/fortwaynedentalgroup.com\/wp-content\/uploads\/2021\/01\/unnamed.png\" class=\"attachment-full size-full\" alt=\"\" srcset=\"https:\/\/fortwaynedentalgroup.com\/wp-content\/uploads\/2021\/01\/unnamed-200x63.png 200w, https:\/\/fortwaynedentalgroup.com\/wp-content\/uploads\/2021\/01\/unnamed-400x126.png 400w, https:\/\/fortwaynedentalgroup.com\/wp-content\/uploads\/2021\/01\/unnamed.png 512w\" sizes=\"(min-width: 2200px) 100vw, (min-width: 915px) 221px, (min-width: 824px) 295px, (min-width: 732px) 443px, (min-width: 640px) 732px, \" \/><\/div><\/div><\/div><div class=\"swiper-slide\"><div class=\"fusion-carousel-item-wrapper\"><div class=\"fusion-image-wrapper hover-type-none\"><img decoding=\"async\" width=\"343\" height=\"118\" src=\"https:\/\/fortwaynedentalgroup.com\/wp-content\/uploads\/2021\/01\/ADA-logo.png\" class=\"attachment-full size-full\" alt=\"\" srcset=\"https:\/\/fortwaynedentalgroup.com\/wp-content\/uploads\/2021\/01\/ADA-logo-200x69.png 200w, https:\/\/fortwaynedentalgroup.com\/wp-content\/uploads\/2021\/01\/ADA-logo.png 343w\" sizes=\"(min-width: 2200px) 100vw, (min-width: 915px) 221px, (min-width: 824px) 295px, (min-width: 732px) 443px, (min-width: 640px) 732px, \" \/><\/div><\/div><\/div><div class=\"swiper-slide\"><div class=\"fusion-carousel-item-wrapper\"><div class=\"fusion-image-wrapper hover-type-none\"><img decoding=\"async\" width=\"512\" height=\"352\" src=\"https:\/\/fortwaynedentalgroup.com\/wp-content\/uploads\/2021\/01\/blueaafelogo.png\" class=\"attachment-full size-full\" alt=\"\" srcset=\"https:\/\/fortwaynedentalgroup.com\/wp-content\/uploads\/2021\/01\/blueaafelogo-200x138.png 200w, 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