*Title & First name

*Last name

Middle initial

*E-mail

Street address

Address (cont.)

City

State/Province

Zip/Postal code

Work phone

Home phone

Additional Phone

Call me at

Best time is

How did you hear about us?

FAX

Check the box at the left if you want to enter the contest and not join the practice as a patient.

If you are a new patient wishing to join our practice please fill out the following questions

When did you last see a dentist?

What was their name?

What was their phone number?

Were x-rays taken?

Yes No

If so when were they taken?

Do you have any chief complaints regarding your mouth?

Do you have any medical alerts or medical allergies that we should be aware of?

Do you have dental insurance?

Yes No

If so, with who?

If so, what is the name of the insured person, their date of birth and social security number and employers name? What is the 800 Number for customer service?