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1
Type Of Appointment
2 Provider
3 Appointment Time
4 Patient Info

EmergencyUrgent Care for New or Existing Patient

New Patient Checkup and Cleaning

Book your appointment for New Patient Checkup and Cleaning lasting [60 minutes].

Any Available Provider

Dr. Kaviani

Book your appointment for New Patient Checkup and Cleaning lasting [60 minutes].

Earliest available appointment date is on Oct 9, 2026

Available Dates

Available Times

Available times will appear once a date is selected.

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Please fill out the information below so we can verify your personal and insurance details, if applicable. Having this information in advance will allow us to verify your benefits before your visit and help ensure a smooth appointment. Once your appointment is booked, our staff will confirm your appointment and details, and we will send you a complete New Patient Form to be completed.

Have you been to our clinic before?

Yes, I am an existing patient

No, I am a new patient

PERSONAL DETAILS

Your personal details. Please review them and make any necessary adjustments.

First Name

Last Name

Gender

Date of Birth

Address

Province/State

City

Postal /Zip Code

Phone #

Type

Ext

Contact Method

Dental Benefit

Do you have any dental coverage?

Yes

If yes, please fill out your insurance info below:

INSURANCE INFORMATION

Your coverage details. Please review them and make any necessary adjustments.

Primary Insurance

Subscriber Name

Relationship

Insurance Company Name

Policy #

Subscriber Date of Birth

Subscriber ID #

Div./Group Number

Employer

Additional Notes

Secondary Insurance