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

  • (Special someone who does not live in your household)

Dental Insurance

  • 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.
  • Patient, Parent, Guardian, or personal representative. The entered name takes effect on behalf of the signature.

Dental History

  • Please a mark on "yes" or "no" to indicate if you have had any of following

Health History

  • Please a mark on "yes" or "no" to indicate if you have had any of following
  • Skip it if you say No.
  • Women

Medication / Allergies

COVID-19 Patient Pre-Screening Form

Make an Appointment

  • We will contact you to confirm the appointment date and time.
  • Drop files here or
    Accepted file types: jpg, gif, png, pdf.
    Upload file: jpg, gif, png, pdf
Please download and complete the form below and bring it to your first visit, if you can not submit the online forms.

DOWNLOAD NEW PATIENTS FORMS