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  • Home
  • Emergency
  • Services
    • Cleaning
    • Gum Disease
    • Custom Dentures
    • Partial Dentures
    • Dental Extraction
    • Bridge
    • Fillings
    • Crowns
    • Dental Implants
    • All-ON-4
    • Invisible Braces
    • Veneers
    • Sedation Dentistry
    • Laser Dentistry
    • Whitening
  • About Us
  • Payment Plans
  • New Patient Forms
  • FAQ

New Patient Forms

Home » New Patient Forms

New Patient Forms - Print, fill out and bring with you to your appointment

  • New Patient Form – ENGLISH
  • Formulario de paciente – ESPAÑOL
  • Authorization for Record Release
Brandon Location
(813) 381-5858

225 Brandon Town Center Dr, Brandon, FL 33511

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Lutz Location
(813) 406-4848

2425 Brunello Trace, Lutz, FL 33558

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Lakeland Location
(863) 648-5353

4912 Southfork Dr, Lakeland, FL 33813

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Brandon Location
(813) 381-5858

225 Brandon Town Center Dr, Brandon, FL 33511

Facebook Twitter Google-plus Instagram Youtube Pinterest
Lutz Location
(813) 406-4848

2425 Brunello Trace, Lutz, FL 33558

Facebook Twitter Google-plus Instagram Youtube Pinterest
Lakeland Location
(863) 648-5353

4912 Southfork Dr, Lakeland, FL 33813

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THE PATIENT AND ANY OTHER PERSON RESPONSIBLE FOR PAYMENT HAS THE RIGHT TO REFUSE TO PAY, CANCEL PAYMENT, OR BE REIMBURSED FOR PAYMENT FOR ANY OTHER SERVICE, EXAMINATION, OR TREATMENT THAT IS PERFORMED AS A RESULT OF AND WITHIN 72 HOURS OF RESPONDING TO THE ADVERTISEMENT FOR THE FREE, DISCOUNTED FEE, OR REDUCED FEE SERVICE, EXAMINATION OR TREATMENT. LICENSE #DN5412. In some but not all cases, fees advertised are minimum fees. Please call with questions or for more details.

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