Welcome to Sequoia Valley Dental Group!

We’re excited to have you as part of our dental family. To provide you with the best possible care, please complete our New Patient Form. This information will help us understand your dental health needs and preferences.

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Personal Information

PERSONAL INFORMATION

First Name

Last Name

Date of Birth

Gender

Address

City

State

Zip Code

Phone Number

Email Address

Insurance Information

INSURANCE INFORMATION

Insurance Provider

Policy Number

Group Number

Policyholder’s Name (if different)

Relationship to Policyholder

Medical History

MEDICAL HISTORY

Primary Care Dentist Name

Phone Number

Please list any current medications (including over-the-counter drugs and supplements)

Do you have any allergies? (If yes, please specify)

Please indicate any past dental conditions (e.g., gum disease, braces, etc.)

Have you had any surgeries or hospitalizations? (If yes, please provide details)

Welcome to Sequoia Valley Dental Group!

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Ready to schedule your appointment? We’re here to help! Contact us today to learn more about our services or to book your visit.