Registration Forms

Designing Smiles

13017 W Linebaugh Avenue, Tampa, Florida 33626

Registration Forms

Designing Smiles 813-891-1212
Angela Hilton-Foley, DMD
______________________________________________________________________________

Please fill out the forms below at your leisure and bring them with you to your first appointment. We look forward to seeing you at your first visit. If you have any questions or need help filling out the forms, feel free to call our office at 813-891-1212.  Welcome to our practice!

                      Please click on the forms below to print.

                                  Health History - Front
                            Health History - Back
                            Dental History
                            Financial Policies
                            HIPPA Forms

To fill out your forms online, please click the link--> New Patient Forms
To Log In---> Patient Information
To request an appointment please fill out the form below. Thank you.

Contact Information

Please indicate the nature of your request, the times that you are most likely available and the best way to contact you. You may also call our office for more immediate help @ 813-891-1212. Thank you!

Reason for Visit:
Requested Appointment Date
Requested Appointment Time
First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code:	(5 digits)
State:
Daytime Phone:
Evening Phone:
Email:
Comments:	Enter comments here!