Patient Form

Please fill the form below

    Patient Information Adult

    Address


    Communication Preferences

    Draw your signature into the box below.*

    Disclaimer: By providing my phone number to Serenity Dental, I agree and acknowledge that Serenity Dental may send text messages to my wireless phone number for any purpose. Message and date rates apply. Message frequency will vary, and you will be able to Opt-out by replying “stop”. Privacy Policy: No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in date and consent; this information will not be share with any third parties.