I want to be a New Patient

Before your first appointment, download the appropriate form below, fill it out, and either fax it to us or bring it with you to the office.

:: New Adult Patient

:: New Child Patient

Contact us to schedule your first appointment by filling out the form below:
First Name:
Last Name:
Birth Date:
  Male: Female:
Address:
Address 2:
City:
State:
Zip:
Phone Number:
Email:
Responsible Party  
First Name:
Last Name:
Responsible Party Work Number:
Appointment Preference:
Who referred you to us?:
Dentist:
   

 
1268 Penn Avenue Wyomissing, PA 19610 Tel: 610.374.4097   Fax: 610.372.8119   Email: braces@fantasticsmiles.com