Forms

We are happy to offer our forms and applications for download.  Please feel free to print these and fill them out at your convenience before your visit.  Please do not email these forms over the Internet.

Heart Valve/Prosthetic Joint Notice

Please read this form if you have any artificial heart valves or artificial joint replacements.
Click here to download (14 KB)

Medical/Dental History

Please complete and bring form to your first dental appointment.
Click here to download (58 KB)

HIPAA Acknowledgement and Medical Records Release

Please complete and bring form to your first dental appointment.
Click here to download (145 KB)

Teeth Bleaching

Please complete and bring form to your first dental appointment.
Click here to download (10 KB)

Smile Assessment

Please complete and bring form to your first dental appointment.
Click here to download (14 KB)

Financial Policy

Please complete and bring form to your first dental appointment.
Click here to download (17 KB)

Notice of Privacy Practices

You do not need to print this document. Please read this notice before your first dental appointment.
Click here to download (133 KB)

 
If you are unable to view the pdf files, please click on the icon below to download and install Adobe Reader:

Dr. Robert Moulton
Dr. Paul Modic
Dr. Julie Murphy
Refresh Dental - Wexford

9758 Perry Hwy
Wexford, PA 15090
Get Directions
 
Phone: (412) 635-9355
 
Office Hours:
By Appointment

Mon 9:00am - 6:30pm
Tues 9:00am - 6:30pm
Wed 9:00am - 5:00pm
Thur 9:00am - 6:30pm
Fri 9:00am - 2:00pm
Sat* 9:00am - 12:00pm

* Limited