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13330 Spring cypress Rd., suite 500 Cypress, TX 77429

Mon-Fri 7 am to 6 pm. Sat and Sun 8Am to 4 pm

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Your Smile. Our Passion.

Our caring dental team is here to support your oral health with comfort and expertise.

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13330 Spring cypress Rd., suite 500 Cypress, TX 77429
2817792672
2816548877
Dr.ali@smilefactorydentaltx.com

Monday : 8:00 AM - 5:00 PM Tuesday : 8:00 AM - 5:00 PM Wednesday : 8:00 AM - 5:00 PM Thursday : 8:00 AM - 5:00 PM Friday : 8:00 AM - 4:00 PM Saturday : Closed Sunday : Closed

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2817792672

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Prefix

First Name

Middle Name

Last Name

Email Address *

Phone *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Date *

Prefix

First Name

Middle Name

Last Name

Phone

Insurance Provider

Policy / Member ID

Upload file

No file chosen

CheckboxDiabetesHeart DiseaseHigh Blood PressureAsthmaThyroid DisorderPregnantNoneOther

Current Medications

Allergies

Reason for Today’s Visit *

Last Dental Visit

Do you experience dental anxiety? *YesNo

CheckboxOption 1Option 2

Consent & Acknowledgment *

I acknowledge the HIPAA Privacy Policy
I consent to dental examination and treatment
I agree to the financial policy

Type Full Name as Signature *

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