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Office Address

7373 N. Scottsdale Road, Suite A-220 Scottsdale, AZ 85253
(480) 991-2290
(480) 991-6933
drkidess@pvsmiles.com

Office Hours

Monday	8:00AM – 5:00PM
Tuesday	8:00AM – 5:00PM
Wednesday	8:00AM – 5:00PM
Thursday	8:00AM – 5:00PM
Friday	8:00AM – 12:00PM

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I understand the information disclosed in this form may be subject to re-disclosure and may no longer be protected by HIPAA privacy regulations and the HITECH act.

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7373 N. Scottsdale Road, Suite A-220 Scottsdale, AZ 85253
(480) 991-2290
(480) 991-6933
drkidess@pvsmiles.com

VIRTUAL CONSULT

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Patient Name*
First Last
Email*
Daytime Phone*
Alternative Phone
I am Interested In
- Regular Appointment
- Virtual Appointment
- Other
Preferred Days*
Time*

: HH

MM

AM/PM
How did you hear about our practice?
How did you find our website?
Tell us about your dental needs*
Comments
This field is for validation purposes and should be left unchanged.