Patient Forms 480-838-3315 Tempe

Dental Emergencies

One smile at a time

Dental Emergencies

Years of advanced training and experience, as well as continued education make Dr. Marc and his experienced team the best choice for your dental care. Whether your visit is a check-up or something more extensive, we are dedicated to meeting your needs. The compassion, attention to detail and friendship you will feel at our office is second to none!

After hours dental advice is available for patients of record on an emergency basis. If an after-hours emergency appointment is warranted, a $100 fee will be assessed.

Contact us today!

APPOINTMENT

Medication & Personal Information

My Personal Information
Name*
First Middle Last
Date of Birth*
Phone Number
Emergency Contact
Name*
Relationship*
Phone Number
Primary Care Physician
Name*
Phone Number
Pharmacy/Drugstore
Name*
Phone Number
Other Physicians
Physician Info
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Name Specialty Phone Number
My Allergies
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My Medical Conditions
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Medications
Be sure to include ALL prescription drugs, over the counter drugs, vitamins and herbal supplements.
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What I'm taking Form (pill, injection, etc) Dosage Home much and when Use (regularly or occasionally) Start/Stop Dates (01/01/19-02/01/19)(01/01/19-ongoing) Notes, directions, reasons for use
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What I'm taking	Form (pill, injection, etc)	Dosage	Home much and when	Use (regularly or occasionally)	Start/Stop Dates (01/01/19-02/01/19)(01/01/19-ongoing)	Notes, directions, reasons for use

Name	Specialty	Phone Number

Name	Specialty	Phone Number

Name	Specialty	Phone Number

Dental Emergencies

One smile at a time

Dental Emergencies

Contact us today!

Our Practice

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