New Patient Inquiry Form

New Patient Inquiry Form

Please fill out this form to become a new patient at our dental practice. We look forward to providing you with excellent dental care.
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Are you currently experiencing any dental pain or discomfort?*

YesNo
Please describe any specific dental concerns or questions you have.
What type of dental services are you interested in?*

Routine CheckupTeeth CleaningCosmetic DentistryRestorative DentistryEmergency Dental CareOther
How did you hear about our dental practice?
Will you be using dental insurance?*

YesNo
Who is your dental insurance carrier? Please note- we can only file claims with PPO plans. We currently do not accept HMO dental plans.

Delta DentalMetLifeGuardianCignaBlue Cross Blue ShieldHumanaUnited HealthcareUnited ConcordiaAmeritasLincoln FinancialOther
If you selected 'Other' above, please specify:
What is your preferred appointment time? Please check all that apply.

Mondays AMMondays PMWednesday AMWednesday PMThursday AMThursday PM
Consent*

I consent to be contacted by this dental practice regarding my inquiry.
Should be Empty: