Rafia Dental
Please Complete All Required Fields. Please enter a valid number. Please enter dates in Month/Day/Year format (mm/dd/yyyy) Please enter a valid time (eg. 12:00 or 14:23). Please enter a valid time (e.g. 1:00 or 14:23). Seperate multiple times with commas. Please enter a valid email address (e.g. username@domain.com). Please enter a valid email address (e.g. username@domain.com). Seperate multiple emails with commas

New Client Information Form: Introduction


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.

* Indicates required fields.


» Step 1. Patient Information




« If the patient is a minor, please provide parent's or guardian's name


« mm/dd/yyyy









» Step 2. Responsible Party/Billing Information




« mm/dd/yyyy









» Step 3. Emergency Contact Information










» Step 4. Insurance Information


« *REQUIRED for MetLife
« mm/dd/yyyy





In case of dual coverage:


« *REQUIRED for MetLife
« mm/dd/yyyy





» Step 5. Pertinent Medical History




Have you ever experienced any of the following? Check all that apply:

Do You Have, Or Have You Had, Any Of The Following?
Are You Allergic To Any Of The Following?
Women: Are You?


» Step 6. Dental History




« Check if "yes"
Select Date « mm/dd/yyyy
Select Date « mm/dd/yyyy
Select Date « mm/dd/yyyy
« Check if "yes"

» Step 7. Agreements






» Step 8. Last Step...


Thank you for your patience. Please click "Submit Form" to send your information to Rafia Dental.