Forms for New Riverside Dental Patients

Please bring your completed forms to our dental office in Leesburg, VA.


Medical History form
New Patient form
Financial Policy form
Records Release form


Your privacy is important to us. All information received in the above forms and through other communications is subject to our Patient Privacy Policy.

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Effective Immediately:
Due to the COVID-19 to ensure the safety of our clientele and staff,In adhering to the guidelines and directives of Governor Northam and the Virginia Board of Dentistry which require dental offices to refrain from performing elective procedures, Riverside Dental is currently closed except for emergencies.If you or a family member should suffer a dental emergency, please do not hesitate to call the office: (703) 727-7447. We will either answer your call, or if you should obtain our voice recording, please just follow directions to contact Dr. Kassem. We look forward to seeing you soon, and will call to reschedule any appointments and notify you when we can reopen. Please everyone, stay safe and stay healthy!