INTAKE FORM
 
 
 

$100 ANY EXTRACTION INCLUDING ALL RADIOGRAPHS and free emergency exam(Introductory promotion)


full mouth exam $30
(Introductory promotion)
All promotions are for non insurance patients
COMPLIMENTARY ROUND TRIP PATIENT TRANSPORTATION AVAILABLE


24 HOUR EMERGENCY SERVICE IS AVAILABLE FOR TREATMENT IN THE FACILITY.
PATIENTS WILL BE ATTENDED TO IN THE OFFICIAL COMPANY CAR BY TWO DENTISTS. (FEES APPLY)

Now screening for one surgical implant candidate for August 23, 2008. This unique opportunity will bring 4 dentists to one patient. The entire procedure will be video recorded for scientific purposes.

ONLINE INTAKE FORMS
1-please fill out and sign all 4 forms for your convenience
2-you can fax or email once you have signed all forms.
Soon you will be able to directly transfer all forms online

 

English

MEDICAL HISTORY

INSURANCE INFORMATION

PATIENT INFORMED CONSENT

PRIVACY FORM


1-follow the above instructions with these three forms

Spanish
MEDICAL HISTORY

PRIVACY FORM
PATIENT INFORMED CONSENT

      phone:702-450-3371
      fax     :702-633-6079
      email  pleasantsmiles@drathari.com