Office Hours: Monday-Friday, 8:30 am - 5:00 pm

Call us to schedule an appointment: (540) 373-6557

242 Butler Road Ste 101, Fredericksburg, VA 22405   Office Location

Delta Dental • Anthem/Blue Cross Blue Shield

Forms For Our Patients

Here at Burns Family Dentistry we intend to provide the best service while being friendly to the environment. Below is a list containing our patient forms in PDF format. You may print and fill out these forms from home and bring them in to our office. Thank you for considering your impact on the environment and helping our planet to stay green!

Form Title PDF Download Version
New Patient Form new_patient_form.pdf
Health History Form health_history_form.pdf
Consent of Health Information consent_of_health_form.pdf
Financial Agreement financial_agreement.pdf
Office Policy Concerning Insurance insurance_policy.pdf
Notice of Privacy Practices notice_privacy.pdf
Acknowledgement of Privacy Practices acknowledgement_privacy.pdf
Patient Missed Appointment Agreement missed_appointment.pdf