Dr J. Kligman • Dr A. Navas • Dr P. Vukasin • Dr M. Sahid

New patient registration form

Welcome to A Better Smile Dental Centre. In order to provide the best possible dental care it is important to have the following information, which will be handled with the utmost confidentiality and will not pass beyond this practice without your written consent.

Please notify us promptly of any changes in your contact details. Accurate contact details help us identify you and your dental records.

Confidential Information

Confidential Medical History

I agree to dental treatment & take full responsibility for payment of my account (or the above-named minor who is under my care)
You can use your mouse (or touch screen) to create a digital representation of your actual signature