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Patient Forms

If you are a new patient to our office, the attached file contains our new patient bundle with forms that will need to be filled out when you arrive at our office. Printing them, filling them out and bringing them with you will allow us to attend to your medical needs more quickly than completing them on your arrival.  Thank you and please call our office if you have any questions at all.

New Patient Registration Form

New Patient Medical History

Patient Record Release Form

HIPAA Privacy Act Form

HIPAA Personal Representative Form


Dental $avings Plan

Dr. Wyne wanted to help individuals who are uninsured. The Dental $avings Plan is for patients with no insurance who want/ need dental care. The D$P is not an insurance plan, but an in-house dental care that is specific to Richard G. Wyne, DDS and can only be utilized in this practice.  For more details, please click on the links below:

D$P Application

D$P Brochure

**To better serve our patients, insurance payments are calculated prior to each appointment and patient balances are due on the date of service.


This web site uses files in Adobe Acrobat Portable Document Format (pdf) which require Adobe® Acrobat® Reader for viewing and printing. It is available to download free.

 





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Dr. Richard G. Wyne, DDS
4110 Aspen Hill Rd Suite 310 Rockville, MD 20853
Phone: (301) 871-7100 URL of Map