New Patient Form

    We are committed to excellence in dentistry and appreciate you taking the time to complete this confidential questionnaire. The better we communicate, the better we can care for you. If you have any questions or need assistance, please contact us - we will be happy to help

    COVID-19 Pre-Screening Questions

    *Required Fields

    For the safety of our team, other patients, and yourself, please be truthful and candid in your answers. If you have been exposed to a communicable disease, you may spread the disease to the dentist, dental staff, or other patients/parents in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission:

    I UNDERSTAND THAT I AM OBLIGATED TO ANSWER THESE QUESTIONS TRUTHFULLY. I ALSO UNDERSTAND IF THE ANSWER TO ANY OF THESE QUESTIONS IS YES, I MAY BE ASKED TO RESCHEDULE TODAY’S DENTAL APPOINTMENT.
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    New Patient Form

    We are committed to excellence in dentistry and appreciate you taking the time to complete this confidential questionnaire. The better we communicate, the better we can care for you. If you have any questions or need assistance, please contact us - we will be happy to help

    New Patient Information

    *Required Fields

    About You

    Please fill all the details Required

    Dental Insurance Information

    Primary Insurance

    Secondary Insurance

    IN CASE OF EMERGENCY, WE SHOULD NOTIFY

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