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Patient Forms

You may access the following forms to assist us with your care. If you are using the online forms, please complete and submit the forms via this website. If you are printing the forms, please print and complete the forms, and bring them to your appointment.

Online Forms

Printable Forms


Get Adobe ReaderThese forms require Adobe Acrobat Reader to view. If you do not have Adobe Reader already installed on your computer, click the Adobe logo to download.

*We are committed to keeping your personal information secure. All of our online forms are submitted via a secure connection and are HIPAA compliant.

***For Apple/Mac Users: You must use Adobe Acrobat Reader to submit the forms. To do so, simply right click on the form and save form. Open form in Acrobat Reader, fill out the form and submit.

Gallia Family Dental

  • Gallia Family Dental - 878 Jackson Pike, Gallipolis, OH 45631 Phone: 740-446-7806 Fax: 740-446-4840

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