Online Patient Questionnaire
Thank you for choosing Kieffer Family Dental as your comprehensive dental health care team. We strive to provide you and your family with the best possible care using the latest technology and skill. We are a clinic filled with competent, caring individuals who display their God-given talents to provide comprehensive patient care and customer service. We are a team. We are united by a deep desire to make a difference in your life. We are committed to caring for you and your dental needs. If at any time you have a question about our practice, please do not hesitate to call. We are excited to serve you!
For your convenience, please fill out all the forms prior to your appointment which are listed below. We look forward to meeting you.
We are asking you to complete new patient questionnaire enabling our clinical and administrative staff to prepare for your first visit and to make your check-in for your appointment quicker and easier.
Our questionnaire consists of 8 documents. To complete a document, simply fill out the fields with the requested information. While most of the fields are optional, certain fields, marked by asterisks, must be completed. When you have completed a document please review your entry, click the Submit button to move to the next document.
Please note that the information you will submit will be encrypted for your protection and goes directly to our office.
We appreciate the time that you will spend providing the information helping us prepare for your visit.
Thank you and please call our office (605) 716-7527 or email to firstname.lastname@example.org if you have any questions.
To start, please click the Start button below.