Patient Forms - Smile Exchange
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Patient Forms

For All Locations

Hatfield Forms (Click to Open)
Online: Hatfield New Patient Registration Form
Please complete each yellow box on each form and upon completion of all forms, click “submit.”

 

Printable Form: Hatfield New Registration Form (pdf)
If you would like to print the form, please complete and bring to your first visit.

Malvern Forms (Click to Open)
Online: Malvern New Patient Registration Form
Please complete each yellow box on each form and upon completion of all forms, click “submit.”

Printable Form: Malvern New Patient Registration (pdf)
If you would like to print the form, please complete and bring to your first visit.

Springfield Forms (Click to Open)
Online: Springfield New Patient Registration Form
Please complete each yellow box on each form and upon completion of all forms, click “submit.”

Printable Form: Springfield New Patient Registration (pdf)
If you would like to print the form, please complete and bring to your first visit.

Trooper Forms (Click to Open)
Online: Trooper New Patient Registration Form
Please complete each yellow box on each form and upon completion of all forms, click “submit.”

Printable Form: Trooper New Patient Registration (pdf)
If you would like to print the form, please complete and bring to your first visit.

Turnersville Forms (Click to Open)
Online: Turnersville New Patient Registration Form
Please complete each yellow box on each form and upon completion of all forms, click “submit.”

Printable Form: Turnersville New Patient Registration (pdf)
If you would like to print the form, please complete and bring to your first visit.

Warrington Forms (Click to Open)
Online: Warrington New Patient Registration Form
Please complete each yellow box on each form and upon completion of all forms, click “submit.”

Printable Form: Warrington New Patient Registration (pdf)
If you would like to print the form, please complete and bring to your first visit.

 Current Offers

$69 New Patient Exam, X-Rays and Cleaning

Your dental care is our top priority. For that reason, we offer a $69 new patient exam, X-rays and cleaning.

* Annual membership fee includes, free of charge: 2 exams, 2 cleanings, 2 oral screenings, 1 X-ray and 1 emergency exam! ($634 value; $599 savings!)
** Does not include abutment and crown.

Terms and Conditions:
The 100% satisfaction guarantee is applicable to the Patient Loyalty Plan only. Refund must be issued within 30 days of activation and prior to starting treatment. For work not started; not valid for previous or ongoing work and cannot be combined with other discounts or dental discount programs. Discount taken off usual and customary fees for general dentistry services. Patients with insurance will receive either the Patient Loyalty Plan discount or insurance plan pricing, whichever discount is greater. Offer must be applied prior to completion of treatment and discount taken upon completion. Subscription payment must be received prior to completion of any services beyond a new patient visit in plan year. Annual renewal is required to remain in program and guarantor assumes responsibility for annual payment for all family. Interruption of subscription during treatment will result in discounts being void and full fee applied to ongoing treatment.