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New Patient Forms

If you are a New Patient visiting us for Dental Implants, Cosmetic Dentistry, or Family Care, please complete the forms below.

Kindly fill the forms and press the 'SUBMIT' button. The information you provide is secure and safe.

Patient Registration

Register online before your first visit to save time.

Fill Registration Form

Health History

Download and review the medical history document.

Download Health History (PDF)

COVID-19 Screening

Required safety screening for all patients.

Fill Screening Form

Appointments & Office Info

Galleria Dental Center
927 Reserve Dr. Ste B, Roseville CA 95678
(Updated Address)

Patients are seen on an appointment basis. We ask that you complete a request or call (916) 780-5678 in advance so that we may reserve an appointment time for you.

Contact Our Office