Dental Questionnaire

Final Step: Fill out the smile assessment below so we can best assist you. 😁

Full Name *

Email *

Phone *

Is this your 1st consultation? If not, what were you unsatisfied with at previous consultations? *

When are you looking to get started? *

We offer different affordable payment plans that are based on your credit approval or a co-signer. Which best describes your current situation? *

I am aware the doctor is reserving this time for me & there may be a $50 no show fee.

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Legacy Dental Co.

Our Location:

17300 El Camino Real Suite 101A, Houston TX 77058

832-637-8462