Clean Smiles Dental Hygiene Clinic

Clean Smiles Dental Hygiene Clinic

Patient Information

Please note: Prior to any dental treatment, our office requires a complete medical history. Knowing any health problems and/or medications you may be taking can avoid problems when treatment commences. Thank you for taking the time to answer these questions.

    If under 18, please complete this section

    Do you have any additional insurance? If yes, please complete the following: