Dental Patient Information Form - United Dental Care, Culver City, Upland California

DR. EFTEKHARI, DDS
Culver City Dentist
Upland Dentist

UNITED DENTAL CARE
3909 S. Sepulveda Blvd.
Culver City, CA 90230
Tel: (310) 390-6000
info@culvercitydentist.com

UPLAND DENTAL PRACTICE
270 E. 7th Street, #1-D
Upland, CA 91786
Tel: (909) 920-6000
Fax: (909) 985-6070

Dr. Referral

Member
California Society of Pediatric Dentistry

Member
American academy of Pediatric Dentistry

Patient Information Form

Your First Name:

Your Last Name:

Your Email Address:

Your Phone Number:

Contact Me By:

I'd Like My Appointment at:

Culver City

Upland

I'd Like My Appointment on This Day:

At This Time:

	:
Hour	Minute	AM/PM

Is This Your First Appointment?:

Tell Us What You Need:

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	Dr. Eftekhari, a Culver City Dentist West Los Angeles Dentist General Dentist Beverly Hills Dentist Kids Dentist California offers Dental Services like: General Dentistry, Pediatric Dentistry, Cosmetic Dentistry, Restorative Dentistry Serving the dental treatment in Culver City, Upland, West Los Angeles, West Wood, Marina Del Rey, Westchester, Mar Vista, LAX airport area
	For more information, call: 310-390-6000 or email: info@culvercitydentist.com	© 2006 United Dental Care, Inc. All rights reserved

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