Request an Appointment

Please do not use this form if you have an urgent medical problem or need to reschedule an existing appointment. Instead, contact our office at (702) 566-5509.

After you submit your request, our appointment scheduler will respond within 48 hours. Please allow extra time if you submit this request on a weekend, we will respond to you on the next business day. Thank you and we are looking forward to seeing you soon at our office.

See below for forms to complete.

Patient Registration Forms

Dedicated Dental in Henderson, Nevada, welcomes you to our practice. Once you have made your initial appointment, you may pre-register by downloading, printing, and completing the forms below. Doing so prior to your visit will help speed up the new patient registration process.

Please be sure to bring all forms with you to your first visit, along with any diagnostic films or other test results that may have been ordered or performed by another physician.

 Downloadable Forms:

NEW PATIENT FORMS:

• Patient Information Form
• Medical History Form
• Financial Agreement Form
• Smile Evaluation Form
• HIPAA Form

RETURNING PATIENT FORMS:

• Patient Information Form
• Medical Update Form

Please note:  It may take a few minutes to load the forms if you are using a slow internet connection. If you are unable to view the forms, you may need to download Adobe Acrobat for free by clicking on the icon below.