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Patient Forms

Please take a minute to print and fill out the patient information form before your first appointment:

Patient Form PDF

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COSMETIC AND IMPLANT DENTISTRY IS NOT RECOGNIZED AS A SPECIALTY AREA BY THE AMERICAN DENTAL ASSOCIATION OR THE FLORIDA BOARD OF DENTISTRY. THE PATIENT AND ANY OTHER PERSON RESPONSIBLE FOR PAYMENT HAS A RIGHT TO REFUSE PAY. CANCEL PAYMENT, OR BE REIMBURSED FOR OTHER SERVICES, AS A RESULT OF AND WITHIN 72 HOURS OF RESPONDING TO THE ADVERTISEMENT FOR THE FREE, DISCOUNTED FEE, OR REDUCED FEE EXAMINATION, OR TREATMENT. NOT VALID WITH OTHER OFFERS OR 3RD PARTY PAYMENT. OFFER VALID FOR CARD HOLDER. OFFER HAS NO CASH VALUE. GENERAL DENTIST LICENSE #DN18196, PAUL ULIASZ | 3448 CLEVELAND AVENUE | FORT MYERS, FL 33901 | (239) 201-2571. THE FEE IS MINIMUM FEE. LIMITED TIME OFFER. HOURS BY APPOINTMENT.

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