Patient Wait List Form

If you would like to be added to our wait list, please fill out the form below and submit it for approval. Someone from our office will get back to you when we via email or phone to discuss your submission.

You may also call us at 775-358-8913
or email Info@CompassionDental.org

Patient Wait List Form

Date(Required)

Initial(Required)

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

D.O.B.(Required)

Phone(Required)

Email(Required)

Do you text?(Required)

Yes

How did you hear about us?(Required)

Monthly Household Income(Required)

# in Household(Required)

Dental Insurance?(Required)

Yes

Insurance Company:

Dental Reason(Required)

Dental Pain? How Severe (1-10)?(Required)

Is the pain constant or occasional?(Required)

What is your dental home regiment:(Required)

Brush

Floss

Rinse

How often?(Required)

Last Dental Cleaning – When?(Required)

Last Dental Cleaning – By Whom?(Required)

Do you have any artificial joints or implanted medical devices in your body (hip, knee, pacemaker, etc.)?(Required)

Surgeon:(Required)

Told to Pre-medicate?(Required)

Medical Doctor:(Required)

Do you take blood thinners?(Required)

Yes

Blood Type:(Required)

Allergies to medication, latex or other?(Required)

Prayer Requests?(Required)

Additional Notes:(Required)

Comments

This field is for validation purposes and should be left unchanged.