Online Patient Questionnaire

We are asking you to complete new patient questionnaire enabling our clinical and administrative staff to prepare for your first visit and to make your check-in for your appointment quicker and easier.

Our questionnaire consists of 4 documents. To complete a document, simply fill out the fields with the requested information. While most of the fields are optional, certain fields, marked by asterisks, must be completed. When you have completed a document please review your entry, click the Submit button to move to the next document. Please don't use your browser's Back or Forward buttons. Use of these buttons may 'undo'/'redo' your recent actions and may result in errors.

Please note that the information you will submit will be encrypted for your protection and goes directly to our office. We appreciate the time that you will spend providing the information helping us prepare for your visit.

Thank you and please call our office (205) 453-0314 or email to medplexpediatricdentistry@yahoo.com if you have any questions.

To start just click here!