Hershey Dentist – Bhargav Patel, DMD - Family, Cosmetic and Implant Dentistry
The first step towards a beautiful, healthy smile is to schedule an appointment. Please contact our office by phone or complete the appointment request form below. Our scheduling coordinator will contact you to confirm your appointment.
Please do not use this form to cancel or change an existing appointment.
Are you a current patient?YesNo
Best time(s) to call?MorningNoonAfternoonEvening
Office Location:575 E.Chocolate Ave HERSHEY, PA 17033
Preferred day(s) of the week for an appointment?Any DayMondayTuesdayWednesdayThursdayFriday
Preferred time(s) for an appointment?MorningNoonAfternoonEvening
What insurance coverage do you have? We do not accept medicaid and Medicare, only PPO and discount plan.
Please Describe the nature of your appointmentCheck-upConsultation
Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.
(The execution of this form does not authorize the release of information other than the terms specifically described below.)
Patient Name:
DOB:
Release To (Office Name):
Release to Dental Office Email:
I request and authorize the above-named doctor or health care provider to release the information specified below to the organization, agency or individual named on this request. I understand that the information to be released includes information regarding the following condition(s):
Information Requested: Copy Of Dental X-Rays
Transfer of RecordsSecond OpinionOther Other Please Explain:
I certify that this request has been made voluntarily and that the information given above is accurate to the best of my knowledge.
Print Name:
Person authorized to sign for patient:
Use Mouse or Finger to make signature:
