New Patient

Welcome to Smiles Dentistry

The following information is required to enable us to provide you with the best possible dental care. All information strictly private and protected by doctor patient confidentiality. Please fill in the entire form.

    PERSONAL INFORMATION

    Dr.Mr.Mrs.Ms.Miss.
    TextEmailPhone Call
    YesNo
    SelfSpouseChildOther
    OnlineAdvertisementWalk inLive / Work in neighborhoodReferral

    Patient Medical Information

    YesNoNot Sure
    YesNoNot Sure
    YesNoNot Sure
    YesNoNot Sure
    YesNoNot Sure
    YesNoNot Sure
    YesNoNot Sure
    YesNoNot Sure
    YesNoNot Sure
    YesNoNot Sure
    YesNoNot Sure
    YesNoNot Sure
    YesNoNot Sure

    Do you nave or have you ever had any of the following?

    YesNoNot Sure
    YesNoNot Sure
    YesNoNot Sure
    YesNoNot Sure

    Patient Dental History

    YesNoNot Sure
    YesNoNot Sure
    YesNoNot Sure
    YesNoNot Sure
    YesNoNot Sure
    YesNoNot Sure
    YesNoNot Sure
    Root Canal
    Orthodontics
    Full or Partial denture
    Periodental (Gums)
    Crown or Caps
    Bridgework
    YesNoNot Sure
    CANCELLATION POLICY

    Smiles Dentistry is dedicated to providing the highest quality dental care for our patients in a timely and efficient manner. In an effort to maintain that efficiency, we attempt to contact every patient at least 2 -3 days prior to their appointment as a courtesy reminder. However, it is the responsibility of the patient to keep their scheduled appointment. In the event you need to make any changes to your scheduled appointment, please let us know 48 hours in advance. Patients that do not call us at least 48 hours prior to their appointment may be subject to a missed appointment fee.

    PATIENT CERTIFICATION AND APPROVAL

    I the undersigned, certify that all of the above medical and dental information is true to my knowledge and I have not omitted any pertinent information.

    PATIENT (GUARDIAN) CONSENT (FOR MINORS)

    I, the undersigned, consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetic as indicated, and I will assume responsibility for fees associated with these procedures.