New Patient Information NameAddressBest Method to Contact:Phone (H)(W)EXT(C)Email Dental Insurance Yes No Name of InsuranceEmployerGroup/PolicyID/CertificateArea of ConcernWhen did the problem start?Last visit to the DentistWere x-rays taken? Yes No What was done?Do you require antibiotics prior to a dental appointment? Yes No Are you taking any medications at this time? Yes No If yes, please bring all medications at first appointment.Cancellation Policy: We require 2 business days' notice to reschedule appointments to avoid a cancellation fee.Payment Policy: We accept Credit Card, Debit Card, or Cash payments only.Consent(Required) By submitting this form, I agree to receive marketing messages, including special offers, updates, and news, and understand I can change my preferences at any time. See our Privacy Policy.(Required)
