Your First Visit

Our mission is to guide our patients along a path of optimal health and wellness for life; to non-judgmentally deliver the highest possible level of care, with empathy and understanding.

At your first visit, you will complete our Patient Information and Health History form. We request all new patients to arrive 10 minutes before their scheduled appointment to complete this form. To save time, you may also complete the form online below.

PATIENT INFORMATION AND HEALTH HISTORY

Patient's First Name*
Patient's Last Name*
Marital Status
- Single
- Married
Date of Birth*
Month
Day
Year
Patient's Address
Street Address Address Line 2 City State ZIP Code
Patient's Phone*
Person Responsible for Account
Name / Relationship
Phone
Address
Street Address Address Line 2 City State ZIP Code
Employed By
Business Phone
Business Address
Street Address Address Line 2 City State ZIP Code
Dental Insurance Plan (if any)
Referred by
Email
This field is for validation purposes and should be left unchanged.

Your First Visit

PATIENT INFORMATION AND HEALTH HISTORY

Person Responsible for Account