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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

Dental History

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

Medical History

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

Emergency Contact

Responsible Party

Is this person currently a patient in our office?

Thanks for submitting!

Contact Us

Fax: 385 - 225-9081


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