261 North Main Street
P.O. Box 187
Dousman, WI 53118

Phone: (262) 965-3662
Fax: (262) 965-3627

New Patient Forms

Welcome to Dousman Family Dentistry!  Before your appointment, we'd like you download and fill out the following sheets.  Both sheets are available in Microsoft Word and Adobe Acrobat PDF format.

Don't have Adobe Acrobat?  Download it here

If you have any questions, call our office at (262) 965-3662.


General Patient Information

Microsoft Word (.DOC)Adobe Acrobat (.PDF)


Medical History

Microsoft Word (.DOC)Adobe Acrobat (.PDF)


HIPPA Notice of Privacy

Adobe Acrobat (.PDF)