Patient Forms

Clearwater family and cosmetic dentist Dr. Jeffrey Ellenberg offers caring and pain-free dental treatment in his state-of-the-art office.  Patient forms are available for review and to fill out prior to your appointment.

Below are a list of patient forms that you can download, print, and fill out before your appointment visit with Dr. Ellenberg.

You can also schedule your next dental appointment with Dr. Ellenberg

If you have any questions, please contact one of Dr. Ellenberg's staff

If you do not have Adobe Acrobat Reader, please download your free Adobe Acrobat Reader software copy

Patient Information Form

Medical History Form

Important Dental Insurance Information

Consent for Use and Disclosure 

Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Policy