I agree to the website  Terms and Conditions and have reviewed the Privacy Policy. 

 The information I have provided is true and accurate to the best of my ability.

By completing this form, I agree to receive automated/pre-recorded phone calls, text messages, as well as reminders 

from the practice but can opt-out at any time. 

I understand that the office does not accept Denti-Cal or Medi-Cal Insurance at this time.