Patient Forms
All of our patient forms are available in PDF format for download.
Please print the necessary forms below and bring them with you to your first appointment.
Please email your completed form to seminolepremierdental@gmail.com
Cleaning, Polishing & Exam
(1110, 0274, 0150)
$95
Regular value of $207 includes necessary x-rays
Emergency Dental Exam
(0140, 0220)
$80
Regular value of $116
Children’s Exam & Cleaning
(0150, 1120, 0272, 1208)
$99
Regular value of $214 includes necessary x-rays & fluoride treatment
Let us make you smile.
