Patient Info

First Name*

Last Name*

Date of Birth*

If patient is a minor

Responsible Party full name:

Relationship

Date of Birth*

Best Days and Times

Select up to 3 appointment dates in order of preference

Optional

Contact Info

Mobile Phone:*(Required)

Email:*

Address:*

Reason for appointment:

How did you hear about us?

Patients who have been seen at our office previously may leave the rest of this form blank, unless your dental insurance or personal history has changed since you were last seen.

Insurance Info

Primary insured full name as shown on policy

Primary insured date of birth:

Insurance Company:

Employer (if plan is sponsored through work):

Telephone number (usually found on the back of the card):

Subscriber or member ID (or social security number):

Group # (if applicable):(Required)

Health Questionnaire

Are you currently pregnant or trying to conceive?

Please list any allergies or medical conditions you have:

Please describe specific concerns you have regarding your dental health, if any:

When was your last dental cleaning (approximation is acceptable)?

Please list the telephone number and address of your preferred pharmacy, if applicable.

PLEASE NOTE: If you have had any x-rays taken elsewhere in the last 12 months: Contact your previous dental office to request that they send ALL xrays to info@box2415.temp.domains prior to your dental appointment to avoid unnecessary out of pocket costs.

Monday	8:00 am – 5:00 pm
Tuesday	8:00 am – 5:00 pm
Wednesday	8:00 am – 5:00 pm
Thursday	8:00 am – 5:00 pm
Friday	8:00 am – 5:00 pm

Appointments