Please fill out the form below to request an appointment with Dr. Wong. We will do our best to set a time that works for you, then give you a call to confirm your dentist appointment.

Please provide the following contact information:

YOUR NAME

   
 

E-MAIL ADDRESS

   
 
DAY PHONE EVENING PHONE CELL PHONE

     
BEST TIME TO CALL: 
   
     
REASON FOR VISIT  
     

CHILD'S NAME:

   
 
     

DATE OF BIRTH:

   
   
 
AVAILABILITY
MONDAY   A.M.   P.M.  
TUESDAY   A.M.   P.M.  

WEDNESDAY

  A.M.   P.M.  

THURSDAY

  A.M.   P.M.  

For your convenience prior to visiting our office, please Click here to print the New Patient Health History Form, complete the information and bring it with you to your first visit. You may also right-click the preceding link and select "Save Target as..." to save the PDF form to your computer.

To view or print the form you will need Adobe Acrobat Reader.  If you do not have Adobe Acrobat, please click here to download it for free to your computer.

 

 

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Dr. Alicia Wong - Art of Pediatric Dentistry ~ Bellevue, WA
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© 2006 Alicia K. Wong, DMD, MPH, PLLC   All Rights Reserved.
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