9140 Galleria Ct, Naples, FL 34109
Call us Today! (239) 592-5112
Emergency Dentistry
Patient Forms

New Dental Patients in Naples

We love welcoming new patients to Galleria Dentistry! Our team strives to provide you with truly exceptional dental care in a relaxed and caring environment. Your first visit at our Naples, FL office takes about two hours.

New Patient Forms

For your convenience, we’re happy to now offer the forms you’ll need to fill out before your initial appointment online. You can fill them out and submit them to us electronically, or you’re welcome to print them out, fill in the pertinent information, and bring them with you. If you choose the latter, please make sure to arrive around 15 minutes before your appointment starts so that our front desk team has time to input the information into our system.

If you’re using a regular PC, please follow the link below to fill out your form online. Having Adobe Reader downloaded is necessary for this option.

New Patient Questionnaires

 If you’re using an Apple product or you don’t want to submit your info online, please download, print, fill out our forms and bring them with you to your appointment.

Patient Information

Medical History

Financial Policy


Consent to Release Dental Records

While a review of your medical history may not seem that important, this information is critical to safely provide care to you. Medications and previous treatments/surgeries can affect what services we recommend. Hip and knee replacements often require a doctor’s release and premedication before you attend a visit with us. Please make a list of the current medications you’re taking as well, and inform us of any changes at the earliest possible time. In addition to medication and patient forms, please bring the following to your first appointment:


As a service to our patients, we are pleased to offer the CareCredit card, North America’s leading health care payment program. CareCredit has a full range of payment plans to meet every financing need, including no interest* and low interest* options, each with low monthly payments and no upfront costs. It’s easy to apply and you’ll receive an online decision in seconds. Apply now or see our staff for more details.

Meeting the Dentist

Once you’ve been welcomed back from the waiting room, one of our dentists will bring you to the consultation room and review what will be done that day with you. At this time, you’re welcome to express any concerns or questions you may have about your treatment.

Low-Radiation Digital X-Rays

Have you had X-rays taken of your smile by a different practice in the past year? We ask that you please have them forwarded so that our team can consult them for your appointment. If you would like us to request your X-rays, you’ll need to fill out an X-ray release form. We can also take additional X-rays here if needed. X-rays are a vital part of your dental examination because they help us diagnose potential issues that cannot be viewed with the naked eye.

Collecting Information

Our dental team creates a chart of your mouth during your first visit. We’ll also take x-rays and intraoral photos of all your teeth, as well as chart any existing fillings and oral conditions. This helps our doctors diagnose any changes that may occur in the future.

Our dental hygienist performs a probing of gums so they can record areas that may be bleeding or irritated. This information is important when it comes to diagnosing gingivitis or gum disease. They’ll also use VELscope to screen for areas of potentially abnormal cells that could signal the presence of oral cancer. Your dentist performs a thorough exam as well and checks for any abnormalities in the jaw joint.

Dental Cleaning

 Once your exam is finished, we recommend what type of cleaning will be needed. Our hygienist goes over instructions for brushing and flossing at home, as well as specific areas they see that may need special attention. At Galleria Dentistry, our team strongly believes that focusing on prevention, and regular dental cleanings is crucial when it comes to maintaining ideal oral health. After your cleaning, you’ll be able to leave with a smile that feels refreshed.

Any questions? Please don’t hesitate to contact our Naples, FL office if you’d like to know more, or if you’re ready to become our newest patient.

Galleria Dentistry, L.C. is a BBB Accredited Dentist in Naples, FL