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  • New Patient
    Welcome Offer


    The New Patient Welcome offer includes a cleaning by one of our great Hygienists! The Hygienist will also take any necessary X-rays (4 Bite Wings). Once the cleaning is completed, Cosmetic and General Dentist, H. Charles Jelinek Jr., D.D.S., will do a thorough exam and oral cancer check.

    This offer is for new patients only. May not be combined with insurance.

    Complete the form below or call our office to take advantage of this offer!

    Offer Expires 06/23/2018

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Patient Forms

To expedite the new patient registration process, we have attached all of the forms that need to be filled out and brought with you at the time of your appointment. You can also fax them to 703-560-1745 or complete the online registration below.

The first form is the "New Patient Health History". This needs to be filed out completely for your first appointment and thereafter every three years.

The second form is the "Smile Assessment". This form helps us determine your dental needs and wants.

The last two forms are your "HIPPA Privacy Act" and receipt of "Acknowledgement of your Privacy Act". The HIPAA Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of personal health information needed for patient care and other important purposes. For more information you can check out the following website - https://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html

Thank you for your cooperation.

Download and print patient forms:

Online patient registration:

New Patient TMJ Disorder Forms: