• In order to provide you with the best dental care possible, please take a few moments to complete the following questions related to your previous dental care. It is understandable if you need to use approximate dates, however, try to be accurate as posible. This information will greatly assist us in assuring that your dental insurance is remitting payment correctly and that we are not duplicating information that may have be acquired at a previous dental practice.


  • Date format: mm/dd/yyyy