Forms

Patient Information

Complete Our Online Patient Forms

Please complete our online forms below before your appointment. You can also download & print the forms by following the link below.

If you're not able to complete our forms online, please arrive at least 15-minutes early to allow time to complete the medical/dental health questionnaire and the patient information form. If you have a complicated health history, please mail it to our office so that we might review it in advance. Be sure to list all medications with dosages and any natural supplements, attaching an extra sheet if necessary.


Referring Doctors Online Forms

At Acharya Periodontics & Implants, we value our relationships with referring dental practices and are proud to partner with you in providing excellent oral healthcare to our community.

Doctors may refer patients to our office by filling out our secure online Referral Form below. After you have completed the form, please make sure to click X button at the bottom to automatically send us your information. The security and privacy of patient data are one of our primary concerns and we have taken every precaution to protect it.

  • Review cases thoroughly in advance
  • Refer back to your office for restorations
  • Collaborate with you on treatment plans
  • Are available in an advisory role
  • Offer accommodating scheduling
  • Provide timely assessments and imaging

HIPAA & Privacy Policy

We believe that our medical and other health information is private and should be protected, and we want to know who has this information. The Privacy Rule, a Federal law, gives you rights over your health information and sets rules and limits on who can look at and receive your health information. Learn more about your protected health information.

  • Infographic & General Fact Sheets
  • Online Video Library

Acharya Periodontics COVID-19 Update

The safety and well-being of our patients and staff is a top priority at Acharya Periodontics.
We are adhering to the guidelines set forth by both the CDC and The Virginia Department of Health as
we monitor developments related to Coronavirus Disease 2019 (COVID-19). We will continue to
implement strategies recommended by public health authorities.

As part of our own aseptic routine, we perform regular environmental cleaning that meets guidelines for
viral disinfection. We have also increased the frequency of cleanings and broad-spectrum disinfectants
used throughout the building. As usual, our patient areas are sanitized and sterilized as recommended
by the American Dental Association.

We will continue to monitor the situation, seek guidance and best practices from the appropriate health
authorities and share additional information as warranted.

We request that any patient, guest or any other member of Acharya Periodontics who does not feel
well, exhibits signs of infection, or has been in proximity to infected persons avoid entering the
premises.

Also, if you have traveled within the last 2 weeks international or domestic, please inform our staff via
telephone or email before your visit.

We will be glad to reschedule any appointments. Please call us at 540-283-0959 or email at
frontdesk@acharyaperiodontics.com .