Smiles Encino - Welcome to our practice

Welcome our practice!
We are delighted to welcome you to our practice and are pleased that you chose US to serve your dental needs. We are serious about providing superior dental care at reasonable prices, and proud of our dedication to our patients. Our goal is to help you feel and look your best through excellent dental care. We look forward to seeing you on a regular basis. Please fill out these forms completely. If you have a question about anything on this form, a team member can assist you.
Todays Date

MonthDayYear
Date
How did you hear about our office
Last
First
M
Preferred name
Gender
Family Status
MMDDYYYY
SSN
Driver License
Address
SuiteApt
City
State
Zip
Home Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Cell #
Format: (000) 000-0000.
Work
Email address
example@example.com
Best form of contact
Employer
Occupation
Emergency Contact Name
Relationship
Contact
Terms and conditions
Undersigned hereby authorizes California Smile Maker to take radio-graphs, study models, photographs, or any other diagnostic aids deemed appropriate to make a thorough diagnosis of any underlying oral conditions or areas of concern.
PatientGuardian Signature
Date

MonthDayYear
Date
Name if not the patient
Relationship to the patient
Should be Empty:

Welcome our practice!