Wilmington Dentist Dan Dube

New Patient Forms

Please fill out the following forms prior to coming to our office and bring with you to your first appointment.

New Patient Package

Medical History

Record Release Form
Please email this to your previous dentist

Record Release Form
From Dan K. Dube, D.M.D.


*HIPAA stands for Health Insurance Portability and Accountability Act. It is a set of standards created by the U.S. Congress to streamline the flow of information in the healthcare system and protect your personal health information. As part of our compliance with HIPAA, we provide you with a notice of Privacy Practices and ask you to sign a form acknowledging your receipt of the Notice.