Please print and fill out these forms prior to your first dental appointment with us. Or feel free to come in early for your appointment and get the forms from us.

 

 

Health Record

Health History

Financial Policy

Patient Acknowledgement

HIPAA

Appointment request
Need an appointment with a dentist in Smith Center ? Requesting an appointment at our Smith Center, KS family and cosmetic dental office 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