Request an Appointment

( * = required field )
*First Name:

*Last Name:

Address Line 1:

Address Line 2:

City:

State:

Zip:

*Phone Number:

*Email:

Interested In:

I am a new patient with no insurance and am interested in the $99 special!
Yes, I'm InterestedNo. I am not new or I have insurance.

Insurance Company
(if applicable):

Comments/Questions:

*Human code:
captcha

 
image_gordonpatientPlease complete all of the forms listed below and bring them with you to your first office visit. If you are unable to complete these forms prior to your office visit, please allow extra time before your appointment to complete them.

Patient Forms

Privacy Documents

Medical Health History Form
Microsoft Word Version
Adobe PDF Version
Notice of Privacy Practices
Microsoft Word Version
Adobe PDF Version
Permission Form
Microsoft Word Version
Adobe PDF Version
HIPPA Forms
Microsoft Word Version
Adobe PDF Version
Registration Form
Microsoft Word Version
Adobe PDF Version
 
Treatment Polices
Microsoft Word Version
Adobe PDF Version
 
White Fillings
Microsoft Word Version
Adobe PDF Version
 
Thank You Form
Microsoft Word Version
Adobe PDF Version
 
EFDA Information
Microsoft Word Version
Adobe PDF Version