LOCATED IN HEART OF VERRADO
PROFESSIONAL AND FRIENDLY STAFF
Prev
Next

WELCOME…..These forms were created to help our team learn more about you, your wishes and needs.
Please read through and complete each section which pertains to you. Thank you.

IF YOU HAVE A MEDICAL EMERGENGY DO NOT SEND CONTACT REQUEST.

Call office during hours of operation OR go to the hospital emergency room.
Emails are handled Monday-Friday 8:30am-5pm ONLY.

 

 

Fieldset


Verification


  • PLEASE NOTE: Our greatest compliment is a referral. As a thank you, when referring friends or family, we offer a $25.00 gift certifi cate/credit towards future treatment. Please take just a moment to fi ll in this portion of our form.
  • There will be a $75.00 fee for any appointments that are scheduled and missed for any reason other than a true hardship emergency. 48 business hours notice is required to avoid the above fee.
  • Everyone’s time is valuable. We have many patients to care for. A missed appointment could have been time given to a patient in need. I have read the above conditions of treatment and payment and agree to their content.


  • If you are wearing a partial or complete artificial denture, please complete the following.




download_btnDownload New Patient Registration Form
download_btnDownload Dental History Form
download_btnDownload Medical History Form


 

We respect your email privacy.
We promise to never sell, barter or rent your email address to any unauthorized third party.
Please be aware that the information above will be sent via email.