New Patient Paperwork

Request Appointment

If you would like to request an appointment at our office, please fill out and submit the form below, or call us at (360) 574-4007. Please note that this is only a request, someone from our office will contact you shortly to confirm a date and time for your appointment.

If your matter is URGENT, or you feel you are experiencing an EMERGENCY, please call us immediately at (360) 574-4007 and DO NOT use the form below.

Patient Information
Name*
First Last
Gender:
Date of Birth
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Contact Information
Day-Time Phone*
Evening Phone
Emergency Contact
First Last
Emergency Contact Phone
Mobile Phone
Email*
Confirm Email*
Referral Information
How did you find out about our practice?
- Clinic Location
- Personal Referral
- Internet Search / Website
- Yellow Pages
- Clinic Sign
- Newspaper / Print Media
- Other
If other, please specify
If Personal Referral, is there someone we can thank for this referral?
Please use this area to give us any other relevant information about yourself or your family
Dental Insurance Information (if applicable)
Insurance Provider
Policy Holder's Name
First Last
Policy Number
Group Number
Medical History
Please list any medical conditions you currently have (e.g., diabetes, heart disease)
Are you currently taking any medications? If yes, please list them:
Do you have any known allergies or sensitivities to medications or materials used in dentistry? If yes, please specify:
Dental History
When was your last dental visit?
MM slash DD slash YYYY
Do you have any specific dental concerns or issues you'd like to discuss during your visit?
Consent for Treatment
I, the undersigned, consent to dental treatment by Salmon Creek Complete Dentistry and their dental team. I understand that the proposed treatment plan and any associated costs will be discussed with me before treatment begins.
Patient's Signature
Date
MM slash DD slash YYYY
Parent/Guardian Signature (if the patient is a minor)
Date
MM slash DD slash YYYY

67979

New Patient Paperwork

If your matter is URGENT, or you feel you are experiencing an EMERGENCY, please call us immediately at (360) 574-4007 and DO NOT use the form below.

Patient Information

Contact Information

Referral Information

Dental Insurance Information (if applicable)

Medical History

Dental History

Consent for Treatment

Contact Info

Office Hours