CHECK IN AT LAKEBRINK DENTAL

This form is to check in for your appointment once you have arrived at Lakebrink-Mitts Dental. Once you have submitted your form, please wait in your car. They will text you when they are ready for you to head on in. Thanks!

Name

First Name

Last Name

Names of other family members with appointments today

Phone Number

I prefer to see: (select all that apply)

DR. LAKEBRINK

DR. MITTS

EITHER

I SEE DR. LAKEBRINK, MY SPOUSE/KIDS SEE DR. MITTS

Dental Insurance

I HAVE THE SAME INSURANCE AS MY LAST VISIT

I HAVE NEW DENTAL INSURANCE (CALL TO CHECK IN 816.792.4455)

I DO NOT HAVE DENTAL INSURANCE