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

(618) 281-9729

Angela Tenholder DMD, FAACP, DABCDSM

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.

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Necessary Forms and Information

Patient Contract

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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

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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

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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

General Consent for Treatment Form

New Patient Forms - Preventative and Restorative Dentistry

Patient History-Adult (docx)

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Patient History-Child (docx)

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Release of Protected Health Information (docx)

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Release of Records to our Office (pdf)

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Adult Craniofacial Pain and Dental Sleep Medicine Forms

New Patient Forms



Synergy Dental New Patient History (docx)

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Medical New PT Paperwork (pdf)

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WatermarkARESQuestionnaire (pdf)

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Headache Assessment (docx)

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M2 patient feedback form (docx)

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Body Pain Assessment Form (docx)

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ALF Therapy/Pediatric Guided Facial Growth

Grow - clinical screening intake form (docx)

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Grow - My Story (docx)

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Grow - Progress Form (docx)

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Whole*istic Dentistry/iHealth Program

Wholeistic choices (docx)

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iSpa Facial Aesthetic Services

SmileSavers In-Office Discount Plan

Pastoral Medical Association COntract

Pastoral Medical Association Contract (docx)

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