New Patient Inquiry Form

New Patient Inquiry Form

Please complete this form to request an appointment. This is not a registration form. If you are scheduled, you will receive separate paperwork to complete before your visit.
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
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
Comfort & Experience

We aim to make your visit as comfortable as possible.
How do you typically feel about dental visits?

Very comfortableA little nervousAnxiousVery anxious/fearful
Have you had any past dental experiences that still affect how you feel about dental visits today?

No, not reallyMaybe a littleYes
What tends to make dental visits harder for you?

Not knowing what is happeningSoundsFeeling rushedFeeling judgedLoss of control
Consent*

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

New Patient Inquiry Form

Comfort & Experience