First Name *

Last Name *

Email *

Phone *

Date of birth *

Gender *

Male
Female
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Reason For Visit *

New Patient

Routine exam & cleaning

Cosmetic Consult

Tooth pain / discomfort

Other

Last dental visit

< 6 months
6–12 months
> 1 year
Not Sure
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Dental Concerns

Bleeding gums

Tooth sensitivity

Jaw pain / clicking

Grinding / clenching

Dental anxiety

Other

Medications *

Allergies

Medical History

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

Insurance Provider

Plan/Group Name or Number

Policy/Member ID

Front of Insurance Card

Back of Insurance Card

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