Thank you for taking the time to complete our New Patient Information form. At Rafia Dental, we are fully compliant with HIPAA regulations, and take your privacy very seriously. Your email address, phone number, or other private information is never sold, leased, or viewed by anyone other than those you have authorized.
This form is SSL encrypted and secured. After secure download at our office, all information entered online will be permanently deleted.
Please complete each section of the form as thoroughly as possible.
Click "Step 1" to begin.
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Thank you for your patience. Please click "Submit Form" to send your information to Rafia Dental.