Intake Form

Fill out our digital intake form before your first visit; saving you from having to fill it out in person.

1Patient Info
2Dental Info
3Medical Info
4Appointments & Costs
5HIPPA Consent
6Patient Consent

Patient Information

P.O. box addresses are not acceptable
If you live within the United States

Responsible Party Information

Only fill out this section if you are not the patient but rather the responsible party. (i.e. the parent of a child)
P.O. box addresses are not acceptable
If you live within the United States

Insurance Information

EMPLOYER INFORMATION
INSURANCE COMPANY INFORMATION
I hereby authorize assignment of my insurance benefits directly to the provider for services rendered. I fully understand am solely responsible for any balance not paid by my insurance company.

Emergency Contact

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