Please use the secure form below to submit your new patient information prior to your visit.
(Insurance will be handled on an individual basis depending upon the plan)
Your insurance company DOES NOT guarantee payment. If after 45 days we do not receive payment from your insurance, you will become responsible for the balance.
Please answer all of the questions to the best of your ability. Anesthetics and other medications that may be necessary in your dental treatment may interact with prescriptions, over the counter drugs, medications and illicit drugs. These interactions may be serious. You must disclose if you are a recovering alcoholic or drug user.
By clicking submit I certify that I have answered the above questions to the best of my knowledge and my medical history is true and correct.