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  • Houston-(713) 347-6833
  • Dallas-(214) 550-7323
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Houston Area

(713) 347-6833

Dallas/Ft. Worth

(214) 550-7323

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Forms

NEW PATIENT REGISTRATION FORMS

Welcome To Our Practice! Below you will find the forms necessary to register the patient, and consent to the first visit. You have the option of filling out the forms directly on this site, or downloading them, printing them and sending them back either via email or by fax.

Click on the best option for you to register

Complete Forms Online

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Download, Print, Complete Then Fax/Mail/Scan Back To Us

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*If using the online forms, please do not use the “Back” or “Forward” buttons in your browser as this might cause you to lose anything you have entered. Please be as thorough as possbile as this will help us prepare for your first visit. The information you provide will be sent directly to our office and we will not share your information without your permission. By using the online forms, you are consenting to the use of Electronic Records and Electronic Signatures.

If you have any questions, please contact us by calling our office at: (713) 347-6833 or by email to: info@mobiledentalassociates.com

CONSENT FORMS

To inform patients about upcoming treatment
Perio Scaling
Oral Surgery
S.D.F.
Fillings
Crown(s)
Bridge(s)
Full Denture(s)
Partial Denture(s)
Denture Repairs
IV Sedation

AFTERCARE INSTRUCTIONS

Helps guide recovery of patients after treatment. For Patients & Caregivers
Perio Scaling
Oral Surgery
S.D.F.
Fillings
Crown(s)
Bridge(s)
Full Denture(s)
Partial Denture(s)
Denture Repairs
IV Sedation

Community Forms

Forms Used By Community Administrators
New Patient Referral
Dental Declaration Form
New Patient Forms Packet Printable/Downloadable

Medical History Update Form
Required Periodically From Existing Patients

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By clicking “SUBMIT NOW,” you agree to receive communication from a member of the Mobile Dental Associates team via phone, email, or text. We prioritize your privacy and do not share your personal information without your consent. You can withdraw your consent at any time by providing written notice.