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	Title & Name: Mrs. Ms. Mr. Dr. * Address: City: Zip Code: Phone: * Call Me At: at home at work at home or work E-mail: * Referred By: Smile Card Referral Radio Ad Yellow Pages Ad Direct Mail Friend / Word of Mouth Magazine / Newspaper Article Yahoo Search Engine Google Search Engine America Online Alta Vista Search Engine Lycos Search Engine HotBot Search Engine Another Search Engine Another Web Site Other Preferred Appointment Date: Preferred Appointment Time: Comments:
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	View our "New Patient Medical & Dental Health History Form" (Adobe Acrobat [.PDF] format)
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	Click here!    Please print, fill out the form completely, and bring with you to your initial dental visit.
	Click on the fading photos to the right to view our office tour!
	Written treatment plan estimates before work is started, so you will always know what to expect Convenient office hours, including early morning, evening, and Saturday appointments Convenient location with ample parking A friendly environment, which facilitates a play area for our wonderful children State-of-the-art facility in a modern and brand new setting 100% modern and up to date infection control protocols in compliance with OSHA requirements Individual sterile water bottle containers in each operatory Placement of anti-retraction valves to disable back flow of contaminated water into the water line system Refreshment counter Relaxation corner
	For your convenience, we accept the following payment methods: Visa, Master Card, American Express, Discover, debit card and cash. In order to keep our fees as economical for you as possible, we require that all payments be paid in full at the time services are rendered. Patients with dental insurance will pay applicable deductibles and co-payments at the time of service.
	At Azmodent Smile Design Dental Group, we respect our valued patient’s time. As a courtesy to other patients who need to be seen for treatment, as well as recognizing our cosmetic dentist’s time, we request that in circumstances where you are unable to keep your appointment, to please call the office at least 24 hours prior to your scheduled time. A fee for any appointments not canceled with sufficient notice will be charged.
	Ask our friendly team members about our seasonal promotions!
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	Gift cards available upon request
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