1000 Eleven South Suite 3F, Columbia, IL 62236, US

(618) 281-9729

(618) 281-9729

  • Home
  • Where to start
  • New Patient Paperwork
  • GROW Program
  • Tongue Tie Assessment
  • Educational History
  • Our Team
  • Training and Technology
  • Patient Resources
  • SmileSavers
  • Provider Resources
  • Testimonials
  • Dr. Tenholder's CV
  • WOPAT sleep device
  • More
    • Home
    • Where to start
    • New Patient Paperwork
    • GROW Program
    • Tongue Tie Assessment
    • Educational History
    • Our Team
    • Training and Technology
    • Patient Resources
    • SmileSavers
    • Provider Resources
    • Testimonials
    • Dr. Tenholder's CV
    • WOPAT sleep device
  • Home
  • Where to start
  • New Patient Paperwork
  • GROW Program
  • Tongue Tie Assessment
  • Educational History
  • Our Team
  • Training and Technology
  • Patient Resources
  • SmileSavers
  • Provider Resources
  • Testimonials
  • Dr. Tenholder's CV
  • WOPAT sleep device

Synergy Dental Solutions

Synergy Dental SolutionsSynergy Dental SolutionsSynergy Dental Solutions

Angela Tenholder DMD, FAACP, DABCDSM,fagd

Angela Tenholder DMD, FAACP, DABCDSM,fagdAngela Tenholder DMD, FAACP, DABCDSM,fagdAngela Tenholder DMD, FAACP, DABCDSM,fagd

Helping you to get started

New Patient Registration Process

Our office is known for its ability to provide unique dental services that support whole body health and function.


This type of customized care requires an additional level of patient cooperation in gathering the information that we need to care for our patients at the highest level of care.


In order to provide the level of service that requires extra attention to be paid to multiple aspects of healthcare as well as from multiple sources, we require the  requested documentation (including any and all imaging/x-rays that are relevant to your care) to be completed and delivered to our office at least 48 hours before your scheduled appointment in our office.  Failure to meet these requirements may result in the cancellation of your scheduled appointment.


PLEASE COMPLETE THE ONLINE PAPERWORK. IF YOU REQUEST A PAPER COPY PLEAE FILL IT OUT AND RETURN TO  WeCare@WeAreSynergy.com OR YOU CAN FAX IT TO 618-281-9734.  If you are sending in paperwork for more than one person please only use the email address. Thank you!

Necessary Forms and Information

Patient Contract

Ongoing updates and Support

Helpful resources

We believe that it is very important to fully inform you of your rights and responsibilities as a patient at Synergy Dental Solutions

What you need to know about your rights and responsibilities before registration

Helpful resources

Ongoing updates and Support

Helpful resources

In order to make the registration process as streamlined as possible we have created easy access to all paperwork and forms required to complete your new patient registration

Ongoing updates and Support

Ongoing updates and Support

Ongoing updates and Support

Providing easy access to our forms and data gathering system will help us to maintain accurate information and the most recent updates on your health and insurance information

New patient forms - all new patients must fill these out

PLEASE SEND US YOUR DENTAL INSURANCE INFORMATION-NOT YOUR MEDICAL.  A COPY OF THE FRONT AND BACK OF THE DENTAL CARD IS APPRECIATED.  Do not send us your medical insurance information.  Doing so will only delay the registration process.  If we need to get records from your previous office please complete the Release of Records form , You may email your insurance card to WeCare@WeAreSynergy.com

New Patient Form (Ages 5+)

New Patient Form (Ages 5+)

New Patient Form (Ages 0-4)

New Patient Form (Ages 0-4)

Dental Records Release

Dental Records Release

Photo Release for Teaching Purposes

Dr Tenholder teaches for several organizations. We kindly ask you to allow us to use images for teaching purposes only.  Other providers outside of Dr Tenholder will NOT be allowed to use or share your images although they may view them for learning purposes.

Photo Release for Teaching

General Consent for Treatment Form

General Consent for treatment (docx)Download

Craniofacial Pain & Sleep Forms- only complete if asked

New Patient Forms



Synergy Dental New Patient History (docx)

Download

Medical New PT Paperwork (pdf)

Download

WatermarkARESQuestionnaire (pdf)

Download

Headache Assessment (docx)

Download

M2 patient feedback form (docx)

Download

Body Pain Assessment Form (docx)

Download

ALF Therapy- complete if requested

Grow - clinical screening intake form (docx)

Download

Grow - My Story (docx)

Download

Grow - Progress Form (docx)

Download

Whole*istic Dentistry- wholeistic preference? fill this out.

Wholeistic choices (docx)

Download

SmileSaver In office insurance plan

SmileSavers Contract 11 South address (docx)Download

iSpa Facial Aesthetic Services

iSpa patient intake form (docx)Download

Pma paperwork - alf and laser patients please complete

PMA memorandum of understanding (docx)

Download

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