Book your appointment | Pride Dental Group

1

Tell us about yourself

Scan your driver's license and we'll fill this in for you. Or just type it in.

Who is this visit for?

How would you like to add your details?

Please choose one

First name From the license

Please add the first name

Last name From the license

Please add the last name

Date of birth From the license

We need this to check your insurance.

Please enter the date of birth as MM/DD/YYYY

Home address

From the license

Please add the home address

How would you like us to contact you?

Choose how you'd like us to contact you

Phone number

Please enter a 10-digit phone number

Email (optional)

Please enter a valid email address

2

Do you have dental insurance?

If you do, snap the front and back of your card and we'll pull out the details for you.

Please choose one

How would you like to add your insurance?

Please choose one

Insurance company From your card

Please add the name of your insurance company

Is your insurance through an employer, or an individual plan?

Please choose one

Whose name is the insurance under?

Please choose one

Member ID number From your card

Please add the member ID

Group number From your card

Please add the group number

My card doesn't have a member ID My card doesn't have a group number

Insurance company phone number From your card

Usually printed on the back of your card.

Please enter the phone number from your card

Insurance mailing address From your card

Please use the claims mailing address printed on your card.

Please add the mailing address from your card

3

When are you generally available?

Tap every day that could work. Pick as many as you like.

We're seeing patients on Mondays and Wednesdays over the next two weeks. We'll reach out to confirm an exact time.

Pick at least one day, or tell us what works in the note below

What time of day works best? Pick any

Anything about your schedule? (optional)

Tell us which days and times work for you

4

Why do we have the pleasure of seeing you?

Please let us know what type of visit you're looking for. If you're in pain, we'll do our best to see you sooner.

Type of visit

Please choose the type of visit

Are you in pain right now?

Please let us know

Anything else we should know? (optional)

Tell us in your own words. Tap the microphone to talk instead of type.

Tap the mic and start talking

Please describe the situation

Thank you for visiting!

Tell us about yourself

Do you have dental insurance?

When are you generally available?

Why do we have the pleasure of seeing you?

Review your answers

Thank you!