New Patients Visit Fremont Dental Office

Are you visiting for the first time?

We value your time. You will be pleased to find that we will generally see you right at the appointed time. We will make every effort to complete your treatment in as few visits as possible. In order for us to be efficient with the time that we have scheduled for you, we would ask that you also be prompt and always give 24 hours notice if you are unable to keep an appointment so that other patients on our waiting list may be served.

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Online Patient Questionnaire

We are asking you to complete new patient questionnaire enabling our clinical and administrative staff to prepare for your first visit and to make your check-in for your appointment quicker and easier.

Please complete the online form below. If you are not able to complete these forms prior to your first visit, please arrive 30 minutes before your scheduled appointment.

Patient Information

Patient Information

Patient Name*
First Last
Date*
SS/HIC/Patient ID#*
Daytime Phone Number*
Work Phone Number*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Sex*
- Male
- Female
- Others
Birthdate*
Status
- Married
- Widowed
- Single
- Minor
- Seperated
- Divorced
Patient Employer / School
Occupation
Patient Employer / School Address
Patient Employer / School Phone Number
Spouse's Name
Spouse's Employer
Spouse's Phone Number
Emergency Contact Name and Phone Number*
(Special someone who does not live in your household)
Whom may we thank for referring you?*
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Dental Insurance

Dental Insurance

Patient Name*
First Last
Who is responsible for this account?*
Relation to Patient*
Insurance Company*
Group Number*
Is Patient Covered by Additional Insurance?*
- Yes
- No
Subscriber's Name*
Birthdate
Relation to Patient?*
Insurance Company*
Subscriber/ID Number*
ASSIGNMENT AND RELEASE
I certify that I, and/or my dependent(s), have insurance coverage with my insurance company(ies) and assign it to Dr. Mioak park all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my name(signature) on all insurance online submissions. The above-named (Dr.Mioak Park) dentist may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for service and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date below.
Agree with above*
- Yes, I agree
Name*
Patient, Parent, Guardian, or personal representative. The entered name takes effect on behalf of the signature.
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Dental History

Health History

Medication / Allergies

Medication / Allergies

Patient Name*
First Last
Email*
List any medications you are currently taking and correlating diagnosis:
Pharmacy Name
Pharmacy Phone
Medication Listing
- Aspirin
- Local Anesthetic
- Barbiturates (Sleeping Pills)
- Penicillin
- Iodeine
- Sulsa
- Lodine
- Latex
- Others
Please tell us about your Allergies*
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Make an Appointment

Make an Appointment

Your Name*
First Last
Daytime Phone Number*
Email*
Have you been seen at Dr. Mioak Park's Office?*
- Yes, I'm an existing patient
- No, I'm a new patient
- I don't remember
Please select desired date*

Office Hours: Tue-Thursday: 8 AM – 5 PM. Friday: 8 AM – 4 PM. We will contact you to confirm the appointment date and time.
Please indicate how you would like to be contacted:*
- Phone
- Text
- Email
Comment*
Attached Documentation (If necessary)
Drop files here or

Accepted file types: jpg, gif, png, pdf.
Upload file: jpg, gif, png, pdf
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