Become a New Patient

To become a new patient simply fill in the information below and our office will contact you to set up your first appointment.

We are happy that you chose Presidio Dental!

Personal Information

First Name:

Last Name:

Middle Initial:

Preferred Name:

Address:

City:

State:

Zip/Postal Code:

Gender Male Female

Date of Birth:

Contact Information

Email: We will not sell or disclose your email address to anyone.

Home Phone:

Work Phone:

Cell Phone:

Insurance Information

Dental Insurance Company Name:

Are you the policy holder? Yes No

Employer Name:

Group Number:

Member ID:

Other Information

Your Message: Please provide any other information that we may need to know. Thank you!