Patient Information

Are you a new patient?*
  • Yes, it is my first time
  • No, I have been seen before
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  • List is empty.
How did you hear about us*
  • I was referred by a dentist
  • I found you on Google search
  • A friend or relative
  • Facebook
  • Instagram
  • TikTok
  • NFED referred me
  • Other
  • No elements found. Consider changing the search query.
  • List is empty.
Preferred Prosthodontist*
  • Carlos Castro DDS, FACP
  • David Zelby DDS
  • MinTae Kim DDS, MS
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  • List is empty.
Preferred Location*
  • Buckhead
  • Duluth
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Preferred Day
  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • No Preference
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  • List is empty.
Preferred Time AM/PM
  • Morning (8:00 am - 11:00 am)
  • Afternoon (2:00 pm - 4:00 pm)
  • Any time
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  • List is empty.
What is the reason for your appointment?*
  • I am looking to improve my overall appereance with veneers or crowns
  • I want to explore the options for fixed teeth on implants
  • I currently have dentures I want to replace for a better option
  • I have a complex dental condition
  • I have missing teeth associated to a congenital condition
  • I have gum disease
  • I am looking for a second opinion
  • Other
  • No elements found. Consider changing the search query.
  • List is empty.

I understand the information disclosed in this form may be subject to re-disclosure and may no longer be protected by HIPAA privacy regulations and the HITECH Act.