New Dental Patient Sign Up

Sign up now and get $50 off your first visit!*

At Jordan River Dental we work hard to make sure that your experience with us from start to finish is a pleasant one. We will work around your schedule and set you up with the soonest available appointment to get your teeth taken care of. You will find that every member of our staff is friendly, professional and you will have a very positive experience at Jordan River Dental.

If you are interested in becoming a patient of Jordan River Dental, please fill out the following short questionaire and one of our friendly staff members will get right back with you to schedule an appointment.

*Your Name:
Phone:
*Email:
Please describe the purpose of your dental visit (i.e. general check up, cleaning, cavity, etc.)
What dates and times work best for you?
*CODE:	(Enter code: jordan2008 for this form to process)

* $50 off special is for new customers only . ONE CERTIFICATE PER FAMILY