New Patient Registration Form

Full Name (First, Last)*

Gender

Male

Female

Date of Birth*

Phone Number (Home, Mobile)*

Email Address*

How did you hear about us?

Message

Phone

Prime Smile Dental

Office Hours

Monday - Thursday	9:00 AM - 7:00 PM
Friday	9:30 AM - 6:00 PM
Saturday	10:00 AM - 4:00 PM
Sunday	Closed (Emergency services available)

Fill out the form below and our team will connect with you in working hours