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Patient's name  Patient's birthdateAge Patient's address Parent's name Email Home phone Work phone ext. Please check the boxes that are applicable: Which office is more convenient for you? Lewisville Plano Which appointment time are you available for a complimentary consultation ? (The initial consultation takes 1 to 1 1/2 hours.) morning (8:00am - 11:20am) afternoon (1:20pm - 4:00) First Available What day of the week would you like an appointment? Monday Tuesday Wednesday Thursday Friday First Available General dentist Date of last exam Do you have orthodontic insurance? YesNo If yes, insurance name Group number Which search engine did you use to find us? AltaVista Aol DogPile Excite Hotbot Infoseek Lycos MSN Webcrawler Yahoo Other... If other, please enter where you found out about us. Comments or Questions Thank you for your time! We will contact you shortly.