Online Patient Form Date MM slash DD slash YYYY Name First Last Date of Birth 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 X-rays Take New X-rays Patient requesting previous x-rays PhoneThis field is for validation purposes and should be left unchanged. Δ
