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Blake Dental Arts


(941) 792-0260

George H. Burgess, D.D.S., P.A.

New Patient Forms

Patient Form Downloads
For your convenience, all new patient paperwork can be accessed online. Simply download each form below, complete the forms at home, and bring the forms with you to your first appointment. If you should have any difficulty downloading these forms, please call our office and a knowledgeable staff member will be happy to assist you.

Health History Questionnaire

Health History Update

Medical Release

New Patient Paperwork

Notice of Privacy Practices (Spanish)

Notice of Privacy Practices (English)

Privacy Notice

Health History Form (Spanish)

X-Ray Release Form

Post Operative Instructions

Treatment Consent Forms


Consent for Periodontal Treatment 


Informed Consent for Oral Sedation

Pre- and Post-Operative Instructions


Instructions for Patients Pre- and Post-Antesthesia


Post LANAP Instructions


Post Operative Instructions for Surgery