We provide a full range of dental services designed to protect your oral health, enhance your smile, and keep you comfortable every step of the way. Whether you speak English or Spanish, need a routine checkup or advanced treatment, you’re in caring, capable hands.
We know your time is valuable, and we want your first appointment at Revive Dentistry to get off to a smooth start. Completing your patient forms in advance means less time in the waiting room and more time focused on your care. Our forms are straightforward and can be filled out at your convenience — at home, on your phone, or wherever works best for you.
Once submitted, your information goes directly to our team so we can review your health history, insurance details, and any concerns before you even walk through the door. It’s one more way we try to make every visit feel prepared, personal, and pressure-free. If you have any questions about what’s being asked or run into any issues, give us a call at (386) 775-4300 and we’ll be happy to help.
Your new patient paperwork covers the essential information Dr. Khezri and our team need to provide you with safe, thorough, and personalized care. This includes your personal and contact information, a health history questionnaire, a list of current medications and allergies, and your dental insurance details if applicable. Having this information on file allows us to tailor your appointment from the very first moment.
Your overall health has a direct impact on your dental care. Our health history form asks about existing conditions, past surgeries, current medications, and known allergies so that Dr. Khezri can make fully informed clinical decisions. This information is kept strictly confidential and is used only to ensure that your treatment is as safe and effective as possible.
We ask about your past dental experiences, any ongoing concerns, and what brings you in — because Dr. Khezri wants to understand where you’re starting from before making any recommendations. Whether you’ve had a great dental history or it’s been years since your last visit, there’s no judgment here. This is a practice built on honesty and forward-looking care.
Patient forms can be completed online using the form below, or you can download and print them to bring to your appointment. We recommend completing them in advance whenever possible — it speeds up your check-in and gives our team time to review your information before you arrive.
If you're completing forms on behalf of a minor or a family member, please make sure all information reflects the patient receiving care. For families bringing multiple members in on the same day, separate forms are required for each individual.
Need help or have a question about the forms? Our team is always available by phone at (386) 775-4300 or by email at Office@ReviveDentistryFL.com. You can also visit us at 272 E Graves Ave, Orange City, FL 32763. We look forward to seeing you soon.
At Revive Dentistry, we offer a comprehensive range of dental services designed to meet the needs of every patient, from routine preventive care to advanced restorative and cosmetic treatments. Whether you’re looking to maintain a healthy smile or transform it, our team is here to help you achieve lasting results with personalized care every step of the way.
Oral surgery can restore your smile and your confidence. We are here to guide you through every step of the process with expert care.
A beautiful smile starts with the right care. At Revive Dentistry, we offer cosmetic solutions tailored to your unique goals and natural features.
Orthodontic treatment at Revive Dentistry is guided by the same philosophy that shapes all of our care: precision, patience, and a genuine focus on you.
From a child’s first visit to adult preventive care, our team makes every family member feel comfortable and confident in the chair.
At Revive Dentistry, the information you share with us is treated with the utmost respect and confidentiality. All patient forms and health records are protected in compliance with HIPAA regulations and stored securely within our practice management systems. We collect only the information we need to deliver safe, high-quality care — nothing more.
If you have concerns about your privacy or how your information is used, please don't hesitate to ask. Our team is transparent about our practices and committed to making sure every patient feels informed and comfortable at every step of the process. Protecting your trust is something we take seriously — in the treatment room and beyond.
Schedule your appointment today and experience personalized dental care that puts your comfort first. Healthy teeth. Confident you.
