Meet Dr. Brown
Meet the Team
Dental Office Mission
Dental Office News
Location and Hours
What We Offer
Our Commitment to You
No Cavity Club
FREE Lifetime Whitening
Mini Dental Implants
Short Term Clear Braces
Snoring and Sleep Apnea
Gum (Periodontal) Therapy
Oral Cancer Screening
Afford Your Dentistry
Forms & Releases
PLEASE FILL OUT AND SUBMIT TO SCHEDULE AN APPOINTMENT OR CALL 281-342-1517
Are You a New Patient or an Existing Patient?
Patients new to our Dental Family, fill out both columns.
Existing Patients, fill out left column.
New to our Dental Family
First and Last Name:
Who Is This Appointment for?
What Are Your Dental Needs or Concerns?
Can We Confirm Dental Appointments via Email?
Do You Accecpt Text Messages?
Mailing Address: Street City State Zip
The Best Way to Contact Me Is:
Once you submit this request we will contact you. Please check the best ways to get in touch with you.
Dr. Brown's Contact Information:
Mon-Thurs 8 to 5
Fri 8 to 4 and Sat 8 to 1
IT IS OUR PLEASURE TO SERVE YOU!
To complete the submission process,
CLICK SUBMIT BUTTON.
How Did You First Hear About Our Office?
Who is Responsible for This Account?
Driver's License Number:
Social Security Number:
Method of Payment:
Please check all that apply:
Is there Dental Insurance that you would like us to research for you?
If Yes, Employed By:
Employee Date of Birth:
Employee SS" or ID Number on Insurance Card:
Name of Insurance Company:
Insurance Company Phone Number:
Do You Have Another Dental Insurance?
In Case of Emergency:
Name and Phone Number of Someone Not Living With You to Notify in Case of Emergency:
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