INTAKE FORM
 
 
 

$100 ANY EXTRACTION
$100 ANY FILLING


24 HOUR EMERGENCY SERVICE IS AVAILABLE FOR TREATMENT IN THE FACILITY.
(FEES APPLY)

Now screening for one surgical implant candidate for August 2009. 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

PATIENT INFORMATION

PATIENT INFORMED CONSENT

PRIVACY FORM


1-follow the above instructions with these three forms

Spanish
MEDICAL HISTORY

PATIENT INFORMATION

PATIENT INFORMED CONSENT
PRIVACY FORM

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