Intake form

Help us serve you better

Name *

Email address *

Phone number

Preferred appointment date

Preferred appointment time

Type of dental service required

Please select at least one option.

Teeth cleaning

Root canal treatment

Extractions

Restorative dentistry

Removable prosthesis

Fixed prosthesis

Pediatric dentistry

Implants

Cosmetic dentistry

Medical history

Are you currently taking any medications?

Do you have any allergies?

How did you hear about us?

Additional questions or comments

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Dr Smita's Dental Clinic