Professional Whitening

Disclaimer:
A. If you are in pain,please call our office directly
B. Appointment requests for persons over 18
years of age must be made by the person that wishes to be seen.


Location:


1st Choice:
   

2nd Choice:
   

Name:


Date of Birth:
- -

Primary Phone:
() -

Secondary Phone:
() -

Email:


For New Patients:
Please fill out the following fields so that
you may be made a patient of record.

Home Address:


City
 
State
 
Zip Code

Insurance Provider


Policy Holder's name


Date of Birth
- -

Relationship to Patient


Who is the Policy Holder employed with?


Insurance ID # or Social Security #


Please enter your message here:

*Fields in blue are required

Click here to read the Disclaimer
I have read the disclaimer:

What you can expect on your first visit
At Cincinnati Dental Services, you're not simply a patient, you're a client. We want you to feel comfortable returning to us for preventive dental care. That's why we strive to make your first visit - and every other visit - as complete, comfortable and informative as possible.

At your first scheduled visit, you can expect your CDS doctor to:
1. Review and evaluate your medical and dental history.

2. Complete visual examination of the mouth, including:

Screening for oral cancer and periodontal (gum) disease
Any other diagnostic aids the examining doctor deems necessary to complete a thorough and accurate diagnosis.

3. Review with you your present dental health and discuss any necessary treatments, including alternative treatments.

4. Provide a detailed written description of the treatment to be performed during each appointment, along with the estimated costs after any insurance payments.

Schedule appointments at your convenience
With early morning, you don't have to miss work or rearrange other daily commitments in order to see your dentists. With several doctors at each office, the one you prefer is usually available when it's convenient for you. And if not, there is nearly always another doctor who can see you at that time.

New Patient Forms

For adult patients please complete the following forms: For younger patients 14 yrs and under, please complete the following forms: *forms best read at 150%

ABOUT SSL CERTIFICATES