Book Appointment

Patient Info
First Name*
Last Name*
Date of Birth*
MM slash DD slash YYYY
If patient is a minor
Responsible Party full name:
Relationship
Date of Birth*
MM slash DD slash YYYY
Best Days and Times
Select up to 3 appointment dates in order of preference
MM slash DD slash YYYY
Optional
MM slash DD slash YYYY
Optional
MM slash DD slash YYYY
Contact Info
Mobile Phone:* *
Email:*
Address:*
Reason for appointment:
How did you hear about us?
Insurance Info
Primary insured full name as shown on policy
Primary insured date of birth:
MM slash DD slash YYYY
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): *
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.

Patient Info