Patient Information Forms

Patient Information

Complete Online Forms

Please click to download & print our office forms listed below to complete before your first appointment. You can also download & print all our other forms & surgical instructions.

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. Be sure to list all medications with dosages and any natural supplements, attaching an extra sheet if necessary.

Also, bring your insurance cards for us to copy and if your general dentist has given you a written referral or x-rays, please remember to bring them with you to your appointment.

To speed up your visit with us, you are welcome to download, print and fill out these forms before you arrive. You may bring them with you or email them to us at frontdesk@acharyaperiodontics.com. If you have any trouble downloading any of these forms, please call our office at (540) 283-0959. Any of our staff members will be happy to assist you.

Patient Document & Form Download

We have made our patient forms and notices available for download. Filling out the required forms ahead of time will expedite your visit with us. The following documents are available as printable PDF files using Adobe Acrobat Reader. If you do not have Adobe Acrobat Reader, download a free copy now from Adobe by clicking here.

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 .