New Dental Patient Application



  • Please select Dental Center and Dentist to meet your primary dental needs.

  • Barnesville Dental:


  • Freeport Dental:


  • Date:

  • Name:


  • DOB:

  • Age:


  • Previous Dentist:

  • Date of Last Dental Visit:

  • *If dental x-rays were taken in the last 12 months, please have previous dentist email to: [email protected]

  • Pharmacy:

  • Name of Insurance:

  • How did you hear about Ohio Hills Health Centers?:








* = Required