Your teeth and your
MAKE YOUR
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New patients - help us help you
Please Complete This Patient Medical Information
Print this page & book your appointment today for a
INITIAL CONSULTATION & DIGITAL X-RAYS
FOR ONLY $25!
Save Time Before Your Next Visit
Dr. Wilcox cares about your teeth, your privacy, and your overall health. If you are a new patient, or if your health has changed since your last visit, please:
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Download this Adobe Acrobat pdf file.
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Don't have Adobe Acrobat Reader?
Click here to download the free program. -
Complete the patient medical history form.
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Fax it to Dr. Wilcox’s office at 505-268-3243, or
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Call 505-268-4484 to book an appointment, and
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Bring the patient information form with you to
your appointment.
The information you provide to Dr. Wilcox remains entirely confidential.
Your personal information will be used only by Dr. Jean-Claude Wilcox and his staff to ensure you receive the best possible dental treatment, and the most cost-effective payment options.
Thank you for helping us to help you!
