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Fort Myers: 239-936-3030 Shell Point Village: 239-454-2233
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Patient
Information

Forms

1

Understand which documents need to be done before your visit

2

Click download and print out each form

3

Fill out each document and bring them in to your next visit

Patient Registration

Leave your name, number, and other relevant information to register with our office. Once you’re in our system, our staff will be able to track your appointments and other vital information. Feel free to print the form or fill it out electronically at your convenience.

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Dental & Medical History

The more we know about your medical and dental history, the better we’ll be able to treat you. Please ensure that you thoroughly read through the medical and dental history form and accurately document your prior ailments and health status.

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Dental Insurance

Many types of insurance are available to assist in covering the cost of dental care. Please provide accurate insurance information on this form and we will file your insurance claim on your behalf. The patient will still be accountable for any uncovered costs.

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Emergency Form

Every detail you can provide is important when we’re treating patients in an emergency. When filling out this form, please be as meticulous as possible, including all information that may help in treating the patient.

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Part of our commitment to serving our patients includes providing information that helps them to make more informed decisions about their oral health needs.

Locations

Douglas E. Milsap, DDS

Fort Myers Office

12530 New Brittany Blvd.
Fort Myers, FL 33907

(239) 936-3030

Shell Point Village Office (Retirement Community)

15000 Shell Point Blvd.
Fort Myers, FL 33908

(239) 454-2233

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© 2017 Douglas E. Milsap, DDS