www.BeautifulTeeth.com
Brock E. Hinton, D.D.S.
Cynthia L. Dominessy, D.D.S.
Maher Atassi, D.M.D.
Michael A. Rodriguez, D.D.S.
Introducing
Phone#
Address
City
State
Zip
Patient's Chief Complaint and Expectations
Evaluation and treatment
Evaluation only
Please send FMX & all current x-rays.
Dates Taken:
Does patient see another DDS, Specialist?
Yes
No
Please List
When treatment is complete, please refer back to office
Yes
No
Appointment Date
Appointment Time
Referred by Dr.
Phone #
5252 Sunrise Blvd., Suite #2
Fair Oaks, CA 95628
(916) 596-3313
Fax (916) 863-6532
1215 Plumas Street, Suite 300
Yuba City, CA 95991
(916) 596-3313
Fax (916) 863-6532
255 West Court St., Building A, Suite #1
Woodland, CA 95695
(916) 596-3313
Fax (530) 661-7112
Patient Validation:
Submit Form
Print Form
Print Form
Print Form