Patient Forms

To help make your visit to Willowdaile Cosmetic and Family in Durham, North Carolina, more convenient, we invite you to download our new patient forms. Be sure to bring the completed forms with you when you come in for your first visit. Our dentists and team look forward to seeing you!

If any of the following apply to you, please also send us these forms prior to your appointment to facilitate your treatment.

  • Records Release Form (If you have had dental X-rays within the last year, please send us this form in advance so we can receive them prior to your visit. Our office requires dental X-rays within the last two years to provide a comprehensive exam. We encourage forwarding of X-rays to limit unnecessary X-ray exposure.)
  • Pregnancy Release Form (If you are pregnant, we need an OB release prior to your first visit.)
  • Prosthetic Joint MD Prophylactic Antibiotic Form (If you have a prosthetic joint, fill out this form.)

Further, the American Heart Association and the American Academy of Orthopedic Surgeons have determined that there are some conditions that require you to take medication prior to your next dental visit. Some of these conditions include, but are not limited to:

  • Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits
  • Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure
  • Repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device
  • Artificial joints

If you have or have had any of these conditions, pre-medication or clarification from your physician will be necessary before any dental treatment can be provided to you due to the health risks involved.

Please contact our office at your earliest convenience concerning any of the listed medical conditions, or if you have further questions, at 919-479-5800 and schedule an appointment with Dr. Simran Kaur and Dr. Matthew Garcia!

Thank you!