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(360) 887-2310

Office Hours

Mon–Tues: 8 AM - 5 PM
Wed–Thu: 7 AM - 4 PM
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Patient Information

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Please type your last name.
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Invalid email address.
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Referred By

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Responsible Party Information

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Responsible Party Spouse

(if different from patient)

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Payment Options

(Choose One, if no option is checked, Payment in full is assumed choice)
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Dental Insurance Information

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If Yes:
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Emergency Contact (NOT living with patient)

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Please Note: 24 Hour Notice is Required for Cancellation to Avoid a Charge

Medical Health History:

Do you have, or have had, any of the following?

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Are you allergic, or have you reacted adversely to any of the following?
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During the last 12 months, have you taken any of the following?
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Women
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