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813-653-1455

1202 Millennium Parkway, Brandon, FL 33511

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First Name *

Last Name *

Phone Number *

Email Address *

Verify Email Address *

Are you a new patient? *

Yes

How did you hear of us?

Is your family, friend or coworker a current patient? We’d love to have their name so we can thank them for referring you to us

How did you hear about our office?

Please provide a brief explanation of the reason for your visit

Are you experiencing pain, swelling, or bleeding? *

Yes

Where is the problem area located? *

Do you have insurance? *

Yes

Who is your dental insurance provider

Best day(s) for your appointment *

Monday

Tuesday

Thursday

Friday

Best time? *

Morning

Afternoon

No Preference

Specific Time

If a specific time is necessary, please indicate the time.

How do you prefer we contact you? *

Phone

Note: we do not accept appointment cancellations via email.

Do you require any special accommodations? *

Yes

Accommodations required

In order to request an appointment you must be 13 years of age or older. *

Yes, I am 13 years of age or older

COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS, P.A.

SmileWright Dentistry welcomes patients with disabilities. If you need an accommodation to receive dental services, we would be happy to provide one. Please contact us at 813-653-1455 to let us know how we may be of assistance. IT IS OUR OFFICE POLICY THAT THE PATIENT AND ANY OTHER PERSON RESPONSIBLE FOR PAYMENT HAS THE RIGHT TO REFUSE TO PAY, CANCEL PAYMENT OR BE REIMBURSED FOR PAYMENT FOR ANY OTHER SERVICE, EXAMINATION OR TREATMENT WHICH IS PERFORMED AS A RESULT OF AND WITHIN 72 HOURS OF RESPONDING TO THE ADVERTISEMENT FOR THE FREE, DISCOUNTED-FEE OR REDUCED-FEE SERVICE, EXAMINATION OR TREATMENT.

DN19817

Monday: 7:00 AM - 5:00 PM

Tuesday: 10:00 AM - 7:00 PM

Thursday: 7:00 AM - 5:00 PM

Friday: 8:00 AM - 5:00 PM

813-653-1455

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