Name:

Phone:

Address:

City:

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Zip:

Email:

SSN #

Date of Birth:

Appt type:

Insurance Compnay:

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Employer:

How did you hear about us?
Click below to fill out our new patient form, medical history, and privacy policy. Then print and bring with you for a faster check in. You can also fax to Lisa @ 704-321-3262 or save to your computer and email to our office at:



office@ghorshifamilydentistry.com


New Patient Info Sheet


Medical History


Privacy Policy


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Take HomeONLY $99
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