New Patient Welcome Form

Welcome to Shoreline Dental Care LLC. We apprectate your confidence in our dental health team and pledge to provide you with the highest level of professional care possible. In order to help us ensure your health and comfort, we ask that you complete SHORELINE the following form. All formation will be held in the strictest confidence. If you have any questions or require help, please ask DENTAL CARE and we will be happy to assist you.

Patient Name

Contact Numbers
Business Address
Name of Spouse or Parent
Address (If Different From Above)
Please Check Appropriate Boxes Below
Children Residing in Household
If Yes Please Provide With The Following:
Physician Name
If Yes Please Provide The Following:
Who do we contact in case of an emergency? Name
In accordance with the Red Flag Rule, we ask that you allow us to retain a copy of your valid photo ID for identification purposes. Thank you.