If you are a new patient please complete our New Patient Form
Preferred Doctor:
Dr. Loveless Dr. Connolly No Preference
Preferred Hygienist:
Jami Nancy Karen Jennifer Roberta Vanessa Melissa No Preference
Monday-Thursday: 8:00-5:00
Friday: 8:00-4:00
1st Choice:
Have you recently received correspondence from Bedford Dental Care regarding either a Hygiene or Doctors appointment to be scheduled? Yes No
Reason for requested Appointment:
Are you experiencing pain? Yes No
If so, please describe that pain(select all that apply): Upper Right Upper Left Lower Right Lower Left
Type of Pain (select all that apply): Sensitive to Hot/Cold Pressure Throbbing Ache
