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New Patient Form

This is the start of your journey with Eagle Canyon Dental Care, please fill out the form so we can get to know you a little better!

Patient Information

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Dental History

Are you nervous about seeing the dentist?
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Do you have braces?
Select all that applies:
Select all that applies:

Medical History

Women Only
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Are you or could be pregnant or nursing?
Are you taking Birth Control Pills?
Please mark if it applies to you
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Are you alergic to any of the following?

Emergency Contact

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Responsible Party

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Is this person currently a patient in our office?

Thanks for submitting!

Contact Us

Fax: 385 - 225-9081

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