(502) 365-2288
Patient Forms Book Appointment

A Commitment to Excellence

We are thrilled to serve as your dental health provider. Not only is everyone working at Smile Academy of Kentucky kind and compassionate, but we also genuinely care about you and your health. We want what is best for your dental health, and we only recommend dental treatment when we think there are no other options. From creating a pleasant office environment to treating you with a gentle touch, we go above and beyond to gain your trust and ensure your satisfaction.

Comfort & Care for the Whole Family

…Because Everyone Deserves a Healthy & Happy Smile

Schedule Now

Your Family is Our Family

Join the Smile Academy of Kentucky family today! We welcome patients in every stage of life to enjoy the benefits of a comfortable, progressive dental practice that is committed to friendly service and the highest quality care possible. Every member of our team strives to gain your trust and build a life-long relationship with you. We look forward to serving as your dental health partner and welcoming you into our dental practice.

Online Forms

Patient Registration

You may preregister with our office by filling out our secure online Patient Registration Form. After you have completed the form, please make sure to press the Complete and Send button at the bottom to automatically send us your information. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

Patient Registration

Health History Update Form

You may preregister with our office by filling out our secure online Health History Update Form Form. After you have completed the form, please make sure to press the Complete and Send button at the bottom to automatically send us your information. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

Health History Update Form

HIPAA Acknowledgement

You may preregister with our office by filling out our secure online HIPAA Acknowledgement Form. After you have completed the form, please make sure to press the Complete and Send button at the bottom to automatically send us your information. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

HIPAA Acknowledgement

Financial Agreement

You may preregister with our office by filling out our secure online Financial Agreement Form. After you have completed the form, please make sure to press the Complete and Send button at the bottom to automatically send us your information. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

Financial Agreement

Cancellation Policy

You may preregister with our office by filling out our secure online Cancellation Policy Form. After you have completed the form, please make sure to press the Complete and Send button at the bottom to automatically send us your information. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

Cancellation Policy

New Patient Forms

Save time by completing our New Patient Forms from the ease and comfort of your own home. Click the Patient Portal button below to complete the forms online through our safe and secure system. For those who prefer to print out the forms, please download, print, and bring them with you to your first appointment. Please call Smile Academy of Kentucky with any questions or concerns.

English Forms

Patient Information - ENGLISH
Health History - ENGLISH
HIPPA - ENGLISH
HIPPA Patient Acknowledgement - ENGLISH
Appointment Cancellation Policy
Financial Policy & Agreement
Dental Records & Release Form

Spanish Forms

Patient Information - SPANISH
Health History - SPANISH
HIPPA - SPANISH
HIPPA Patient Acknowledgement - SPANISH
Política De Cancelación De Citas
Política Financiera Y Acuerdo
Formulario De Divulgación De Registros Dentales

Financial Information

Smile Academy of Kentucky is pleased to accept most dental insurances, including HMOs and DMOs, and Kentucky Medicaid. When you call to schedule your initial visit, please let us know if you will be using insurance so we can verify your coverage. We accept cash and major credit cards for your out-of-pocket responsibility. We also offer a unique membership plan that provides preventive care and discounts on services for a reasonable annual fee. Please call or click below for all the details.

Membership Plan
en English
af Afrikaanssq Albanianam Amharicar Arabichy Armenianaz Azerbaijanieu Basquebe Belarusianbn Bengalibs Bosnianbg Bulgarianca Catalanceb Cebuanony Chichewazh-CN Chinese (Simplified)zh-TW Chinese (Traditional)co Corsicanhr Croatiancs Czechda Danishnl Dutchen Englisheo Esperantoet Estoniantl Filipinofi Finnishfr Frenchfy Frisiangl Galicianka Georgiande Germanel Greekgu Gujaratiht Haitian Creoleha Hausahaw Hawaiianiw Hebrewhi Hindihmn Hmonghu Hungarianis Icelandicig Igboid Indonesianga Irishit Italianja Japanesejw Javanesekn Kannadakk Kazakhkm Khmerko Koreanku Kurdish (Kurmanji)ky Kyrgyzlo Laola Latinlv Latvianlt Lithuanianlb Luxembourgishmk Macedonianmg Malagasyms Malayml Malayalammt Maltesemi Maorimr Marathimn Mongolianmy Myanmar (Burmese)ne Nepalino Norwegianps Pashtofa Persianpl Polishpt Portuguesepa Punjabiro Romanianru Russiansm Samoangd Scottish Gaelicsr Serbianst Sesothosn Shonasd Sindhisi Sinhalask Slovaksl Slovenianso Somalies Spanishsu Sudanesesw Swahilisv Swedishtg Tajikta Tamilte Teluguth Thaitr Turkishuk Ukrainianur Urduuz Uzbekvi Vietnamesecy Welshxh Xhosayi Yiddishyo Yorubazu Zulu