Insurance Name

Ins Member ID

Birthday

Ins Phone #

Nature of Appt

Phone No.

English

Dentist

Existing patients can book appointments here.

Current patient

Worker's Compensation New Patient

Dental Implant Eval, $100 exam, $100 CT scan

New patient forms are available at: https://goo.gl/pnWCFI

Cash Patients: $60 due at appt

Insurance patients: Free if covered by your insurance plan.

New Patient Exam & X-rays, Free to book. Fees due at Appt

Cash patients: $80 for Exam, $108 for panoramic x-ray (waived if you have a panoramic already)

Wisdom Teeth Evaluation. Free to book. Fees due at Appt

Name

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Dentist

Services

Dental Implant Eval, $100 exam, $100 CT scan

New Patient Exam & X-rays, Free to book. Fees due at Appt

Wisdom Teeth Evaluation. Free to book. Fees due at Appt

Current patient

Worker's Compensation New Patient

Address

Dentist

Dentist

Opening hours

Services

Dental Implant Eval, $100 exam, $100 CT scan

New Patient Exam & X-rays, Free to book. Fees due at Appt

Wisdom Teeth Evaluation. Free to book. Fees due at Appt

Current patient

Worker's Compensation New Patient

Address

Opening hours