cosmetic
Accreditation
Six Month Smiles™
general
Technology
Sleep Apnea / Snoring
reconstructive
sedation
cosmetic
Accreditation
Six Month Smiles™
general
Technology
Sleep Apnea / Snoring
reconstructive
sedation
about
Our Practice Philosophy
What Our Patients Say
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Before & After Gallery
Patient Reviews
about
Our Practice Philosophy
What Our Patients Say
gallery
new patients
Make Appointment
Financial Options & Insurance
Pre-registration
Before & After Gallery
Patient Reviews
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patient screening
First Name
Middle Initial
Last Name
Nickname
Do you have a fever or have you experienced a fever in the past 14 days?
Yes
No
Are you taking any fever reducing medications such as Aspirin, Tylenol, or Ibuprofen?
Yes
No
Have you experienced recent onset of respiratory problems, such as a cough or difficulty breathing, within the past 14 days?
Yes
No
Have you experienced recent loss of taste or smell?
Yes
No
Have you traveled inside or outside of the country within the last 14 days?
Yes
No
Have you come into contact with a person with confirmed COVID-19 infection within the past 14 days?
Yes
No
Have you received a COVID-19 vaccination?
Select
Yes
No
Update on Information
By checking this box you are agreeing to contact us within 24 hours before your scheduled appointment if there are any changes to the above answered questions.
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