New Patient Registration
Welcome to Newbury Smiles Dentistry! Please complete this form to help us provide you with the best care possible.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Have Dental Insurance?
Yes, PPO Dental Insurance
Yes, HMO/DENTICAL
No, Paying out of pocket
I acknowledge that Oxnard Gentle Dentistry only accepts PPO insurances
*
I acknowledge
Preferred Contact Method
*
Phone
Email
Text Message
Phone or Text Message
Reason for Visit
*
😰 Sudden Tooth Sensitivity
🦷 Emergency Tooth Extraction
🧬 Root Canal
😣 Swelling in Jaw or Face
😖 TMJ Treatment
🥱 Sleep Apnea
💥 Broken or Cracked Tooth
👑 Lost Crown or Filling
📋 Not Sure — Need Consultation
🪥 Routine Cleaning
🩺 Dental Exam
👨⚕️ Consultation
😬 Clear Aligners
Other
Brief Dental History Overview (past treatments, ongoing issues, etc.)
*
Submit Registration
Should be Empty: