New Patient Form

If you are a new patient, please submit the following form

This submission will be encrypted and only seen by the required staff. If you would like to print out the form instead to complete, please print our PDF version here.

Insurance #1
Insurance #2
Medical History
For Women

Consent to Photograph

I, the undersigned, give permission to Smiles Dental Group, and/or parties designated by Smiles Dental Group and/or 8 Cubed Holdings to photograph/ video me and use such photograph(s)/ video(s) in all forms of media, for any and all promotional purposes including advertising, display, audiovisual, exhibition or editorial use.

I further consent to the use of my name in connection with the photograph/ video if needed by Smiles Dental Group, and/or parties designated by Smiles Dental Group. I understand and agree that I will not receive any payment for time or expenses or any royalty for the publication of the photograph/video or the use of my name and I hereby release the Smiles Dental Group and/or parties designated by Smiles Dental Group from any such claims.

I certify that I have read and fully understand this consent and release, and that all the questions pertaining to this consent have been answered to my satisfaction.

Office Policies Form

Welcome to Smiles Dental Group. You have many choices when it comes to choosing a dental office, and we are glad that you have chosen us to provide you and your family with the most advance dental treatments available. Everyone at our office is committed to providing quality dental care in a comfortable environment. Please take a few minutes to familiarize yourself with our office hours and policies.

1. Although many dental offices are non assignment, our office will accept direct billing of benefits from your insurance company as part of our client services. It is important for you to understand that there may be differences between our fees and what your insurance company will pay for treatment. You are responsible for any difference in fees.

2. In order to provide direct billing to our patients, we will require our patients to provide us with a credit card of file. If we cannot calculate your balance at your dental visit with certainty, you will be required to pay 30% deposit. This may result in a small balance or credit on your account. If a balance still remains