909-383-8931

PATIENT INTAKE FORMS

Our friendly staff is eager to assist you in achieving lifelong dental health in a welcoming environment. For a streamlined start to your treatment, download and complete these forms. Bringing them to your appointment will expedite the process.

PATIENT INFORMATION

(Please fill out as completely as possible)

RESPONSIBLE PARTY INFORMATION

PRIMARY INSURANCE INFORMATION

(NOTE: Social Security numbers are still required by some insurance carriers)

If yes, then please complete the following secondary insurance

SECONDARY INSURANCE INFORMATION

(NOTE: Social Security numbers are still required by some insurance carriers)

I verify that the above information is correct and complete to the best of my knowledge. I also verify that I have read and understand the Informed Consent form, and I have been given directions on how to access a copy of the general Office Policies. (Copy of the Imformed Consent form is available upon request).

909-383-8931

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