Cary Office Click To Call
(919) 865-0700
1110 SE Cary Parkway Ste # 206
Cary, NC 27518, USA | Directions
Cornelius Office Click To Call
(704) 765-3150
20905 Torrence Chapel Rd #201
Cornelius, NC 28031, USA | Directions
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*Patient Last Name :
*First Name :
M.I. :
*Date of Birth :
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*Patient Address :
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Note :Care Credit are not accepted.
Dental insurance coverage
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* I consent to the diagnostic procedures and treatment necessary for proper dental care. I consent to the dentist’s use and disclosure of my records (or my child’s) to carry out treatment, to obtain payment and for those activities and health care operations that are related to treatment or payment. My consent to disclosure of my Records shall be in effect until I revoke it in writing.
* I attest to the accuracy of the information I have provided on this page.
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