Dental Forms

Download Your Dental Forms

For first time patients: Please “Print and Fill-out”, before your first appointment.

Information Forms

Please use the forms below,
to provide personal & medical information.

HIPAA & Consent for Use & Disclosure

Please use the forms below for the consent of limited use of health information & acknowledgement/receipt of our privacy practices.

Statement of Privacy Practices
-A printed copy can be provided upon your request.

For Over 30 years we have been serving the Rochester Area with our unique approach to dentistry. We treat every patient like family.

About Our Clinic

We only schedule “One Patient At-A-Time”! 30+ Years Experience; Located in Brighton, NY.

Known as the gentle dentists, Dr. Fred Blum and Dr. Caprice Dakwar are located in the 12-corners area of Brighton, near Rochester New York. Our doctors and hygienists never schedule more than one patient at a time so we have personalized time to explain every treatment option and procedure.

Serving the Greater Rochester Area for over 30 years – from gentle wisdom tooth extraction, dental implants, braces and general dentistry – we perform all services with your comfort in mind.

Smile Makover
Teeth Cleaning
Gentle Dentist

Do You Have Any Questions?