Palmdale Dentist - Patient Forms

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Patient Forms

For your convenience, we have supplied a Health History Form in pdf format. If you wish, click on the link below, print, complete the form at home, and bring it with you to your first visit! We look forward to greeting you!

Dental Health Form

Medical History Form

Adobe Acrobat Free Reader

New Patient Offer

Six Month Smiles
$500 Off Any New Case
Free Consultation

Sedation
Now 50% Off

Free Bleaching
or $50 Gas Card
(with New patient cleaning,
x-rays and exam)
-Limit 2 per Family-

Offer Expires: 02/09/2012

<div style="text-align: center"><span style="color: rgb(255,0,0)"><strong><span style="font-size: medium"><br />
</span><span style="font-size: large"><span style="color: rgb(255,0,0)">New Patient Offer</span></span></strong></span><strong><span style="font-size: medium"><br />
</span></strong></div>
<div style="text-align: center"> </div>
<div style="text-align: center"><strong>Six Month Smiles</strong><br />
$500 Off Any New Case<br />
Free Consultation<br />
 </div>
<div style="text-align: center"><a target="_blank" href="/Simmons-Gift-Certificate.pdf"><img border="1px;" border-color="black" alt="Give the gift of health" src="/images/Gift-Cert-Small.jpg" /></a><br />
<br />
 </div>
<div style="text-align: center"><strong>Sedation</strong><br />
Now 50% Off<br />
 </div>
<div style="text-align: center"><strong>Free Bleaching <br />
or $50 Gas Card</strong><br />
(with New patient cleaning, <br />
x-rays and exam)<br />
<span style="color: rgb(128,0,0)">-Limit 2 per Family-</span><br />
<br />
<span style="color: rgb(255,0,0)">Offer Expires:</span>  02/09/2012<br />
<br />
<br />
 </div>

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Palmdale Dentists · Simmons Dental Care · 1029 Elizabeth Lake Road · Palmdale, CA · 93551