We would like to welcome you to our office as a new patient.

Please take a few minutes to fill out the New Patient Questionnaires, Health History and applicable Consent Forms. This will help us prepare for your visit and make your overall experience enjoyable, prompt and efficient.

These forms are strictly confidential and should be filled in and printed out prior to your visit. If this is not possible or convenient for you to accomplish, please come into the office 15-20 minutes prior to your appointment to fill out these forms.

Financial Policy – Required
H.I.P.A.A. – Required
Informed Consent – Required
Materials Fact Sheet
Medical History – Required
Patient Registration – Required

 

New Patient Questionnaire

Your Name (required)

Address (required)

Phone No. (required)

Your Email (required)

How did you hear about us?

Are you interested in having a beautiful smile?
YesNo

Would you like to make an appointment?
YesNo

Questions or comments