• New Patient Pass

    Schedule an appointment today for a New Patient Comprehensive Oral Exam, Full-mouth Digital X-ray Series and Consultation for $75. This is a $217 value!

    For 1st time patients only. Can not be combined with other offers. Must present Patient Pass at time of appointment. Restrictions may apply. 

    Offer Expires 07/23/2021

COVID-19 Patient Screening Form

Patient Name:
Date:
Phone Number:
Email Address:
Have you had any symptoms of Covid-19? (Fever, headache, sore throat, cough)
Yes No
Have you been tested for Covid-19 in the past 14 days or are you waiting for results for a test?
Yes No
Have you started / completed the Covid-19 Vaccine?
Yes No

Positive responses to any of these would likely indicate a deeper discussion with the dentist before with elective dental treatment.

For testing, see the list of state and Territorial Health Department Websites for your specific area's information.

Medical History Update:

Have you seen a Doctor since your last visit?
Have you been diagnosed with anything new?
Have you had any surgeries since your last visit?
Are you taking any new medications since your last visit?
Please list all medicines, including any over-the-counter, vitamins and/or supplements.
Do you have any dental concerns at this time? Broken tooth? Tooth ache?

 

Patient Information Update:

Address:
Cell Phone #:
Email:
Dental Insurance:

Please enter code above in the field below.

Our office is close to Northpark Mall.

Office Hours:

  • Monday 09:00am - 05:00pm
  • Tuesday 08:00am - 05:00pm
  • Wednesday 08:00am - 05:00pm
  • Thursday 07:00am - 03:00pm
  • Friday Closed
  • On Mondays, Tuesdays, and Wednesdays,
    we are closed from 1:00-2:00 p.m. for lunch.