New Patient Intake Form | Specialty Smiles by Dr. Gromov Please Fill Out Our Secure Form New Patient Intake First Name* Last Name* Email Address* Phone Number* I prefer to be contacted by* Phone Email Either How can we brighten your smile? What are your major concerns? * Replace a missing tooth or several teeth Get rid of the removable denture I want to change the shape of my teeth - Please specify in the comments I want my teeth to be whiter I want to change the shape of my gums - Please specify in the comments Broken tooth, cracked tooth, chipped tooth - Please specify in the comments Tooth Sensitivity - Please specify in the comments Tooth Pain - Please specify in the comments My dentist send me to a specialist but they don't accept my insurance Something else - Please specify in the comments Any additional comment. Please list any relevant information so we can serve your dental needs better.Sign FormTo be the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.I consent to use Electronic Records and Signatures. I consent to use Electronic Records and Signatures. See Electronic Records and Signatures Disclosure. ** Relationship to patient **SelfParentSpouseGuardianOtherName
