Patient Intake Form

First Name *

Last Name *

Zip Code *

Email *

Phone *

Date of Birth *

How did you hear about us? *

Insurance Carrier *

Other Insurance (if you selected other from the dropdown menu, please specify here)

Insurance Policy # *

Insurance Group # *

Employer

Policy Holder First Name *

Policy Holder Last Name *

Policy Holder Date of Birth *

Chief Complaint and/or Become Established Patient*

Last Dental Visit *

Have you had dental x-rays taken in the last year? *

Do you have any history of deep cleanings?*

Any other additional comments or concerns?

Best days for appointment?*

Best time for appointment?*

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.