Please print, fill out and bring the following forms with you at your next appointment.

First Visit forms
Office Policy/Financial Policy form
New Patient Health form
New Patient History form
Patient Financial Agreement and Consent form

Insurance form
ADA Dental form

 

 

Children's Dentist in Santa Maria, CA 93454 - Dr. Samuel Burg, Dr. Rick Kleinsasser, and Dr. Henry Arakaki ~ General Dentists Limited to Children and Teens

Servicing patients in the surrounding cities and areas of Santa Maria, California 93454

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