Patient Forms for Smiles by Design

Everyone here at Smiles by Design values your time as our patients. If you are new to our office please print and fill out the forms below, and bring them with you on your first visit. We look forward to seeing you!

 

 

New Patient Forms

 

PATIENT INFORMATION

INSURANCE AUTHORIZATION FORM

MEDICAL HISTORY INFORMATION

DENTAL HISTORY INFORMATION

FINANCIAL POLICY

NOTICE OF PRIVACY PRACTICES

ORAL CANCER SCREENING

 

Please print and fill out all forms before your appointment. If possible, please email to oceansidefamilydental@gmail.com

Appointment request
Requesting an appointment at Smiles By Design is now easier than ever. Fill out the form below and we'll contact you to find a time that fits your schedule. Start your journey towards a beautiful smile with us today!
Patient Name*
Phone Number*
Email Address
Are you a current patient?
Best time(s) to call?
Choose Location:
Preferred Appt Date
Preferred Appt Time
Message
Describe the nature of your appointment or any other comments