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Patient Forms - Patient Info Sheet

Our goal is to help you reach and maintain maximum oral health. Please fill out the form completely. The better we communicate, the better we can care for you. Thank you and we are glad you are here!

If you would prefer to print out the form and bring it with you, click on the link below. Otherwise an online form has been provided below. Thank you for answering the following questions.

Patient Info Form (pdf)

About Child

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 / 
 Male  Female

Mother's Information

 Yes  No
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 Y  N

Father's Information

 Yes  No
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 ) 
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 - 
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 ) 
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 / 
 / 
 - 
 - 
 Y  N

Dental Insurance Information

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 / 
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 ) 
 - 

Dental History

 Yes  No
 Yes  No


14221 Metcalf Ave
Suite 100
Overland Park, Kansas 66223

Phone: 913.851.5900
Fax: 913.851.5912

Email: info@lenzdds.com


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To contact us CALL 913.851.5900
or fill out the online form below and we will contact you.

Our Hours

Monday
Tuesday
Wednesday
Thursday
First Friday
of each month
8:00 a.m. - 5:00 p.m.
8:00 a.m. - 5:00 p.m.
8:00 a.m. - 5:00 p.m.
7:00 a.m. - 4:00 p.m.
7:00 a.m. - 2:00 p.m.
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