Online Patient Form Date Date Format: MM slash DD slash YYYY Name First Last Date of Birth Date Format: MM slash DD slash YYYY PhoneEmail Who may we thank for referring you to our office?Please tell me about your dental history:We ask that all new patients joining the practice take care of any fees on the first visit, regardless of insurance involvement. If you and the doctors agree on a treatment plan, we will explain all treatment estimates to you at that time and do our best to assist you with getting the most from any dental insurance you may have. Please know that we will not proceed with any treatment without your permission. The fee for the 2-hour new patient intake process is $300 and includes: 30–40-minute preclinical interview—comprehensive review of medical/dental history Appropriate x-rays, including 2D and 3D cone beam as possibilities Complete dental exam including evaluation of: submandibular and cervical lymph node oral soft tissue exam analysis of the TMJ/bite function periodontal evaluation tooth by tooth examination for decay and status of existing restorations\ evaluation of any existing dental prostheses screening for potentially toxic materials in the oral environment evaluation of any root canal teeth and cavitations via CBCT if their referring practitioner and the patient agree in the importance of this We accept any current (within 1 year) 2D x-rays from other dentists, but if we need to take our own full mouth series of x-rays, the fee is $146. We need the information from the 2D x-rays for diagnosis of periodontal health, decay, and condition of existing restorations.X-rays Take New X-rays Patient requesting previous x-rays Patients going directly to hygiene: Do you have any artificial bones, joints, or heart conditions?Would you like me to pull your insurance benefits for future appointments?Insurance CoPhoneMember #/SSNGroup #Subscriber Name if not PatientSubscriber DOBPhoneThis field is for validation purposes and should be left unchanged.