New Patient Inquiry | Los Osos Family Dentistry

1Are you an existing patient with our practice? *

Yes No

2Will you be using insurance for this appointment? *

Yes No

3What is the reason you need a dental visit? *

Let us know what you need so we can make sure you get the best care — even if it's just a checkup!

Checkup & Cleaning Specific Treatment Urgent Issue

4Do you have a preferred time to see the dentist? *

Early (before 9am) Morning (9am – 12pm) Noon (12pm – 2pm) Afternoon (2pm – 5pm)

5How soon do you want to visit the dentist? *

As soon as possible Within 1 week Within 2 weeks In more than 2 weeks

6Are you experiencing any kind of pain? *

Yes No

7What is your name? *

8What is the best phone number to reach you at? *

9What is your email address? *

Please provide your email address.

10When would be a good time for our staff to reach you and confirm the appointment? *

Should we contact you via phone or email? Would it be better to call in the morning or afternoon?