image of Hi5 Ortho Logo
• Beaverton: (503) 644-4749 • Hillsboro: (503) 642-1535 • Portland (Cedar Hills): (971) 713-3899

slide show image Hi5 dental patient reviews 2
slide show image Hi5 dental patient reviews 2

Hi5 Dental is proud to announce a new location in Beaverton, OR!


We have moved Pediatric dentistry services to our Beaverton practice and our Cedar Hills practice will provide Orthodontic services!

Patient Information Form

 

The information provided on this form is important to your children's health. Please complete all of questions to the best of your ability. If there have been any changes in your health, please tell us. Questions are welcome and appreciated.

 

The security of your information is very important to us. This form is fully secure and your information will be protected. To learn more about the security measures used on this form, click the security logo to the right.

 

Contact Information

Preferred Hi5 Dental Location:

Cedar Hills Hillsboro  

 

How did you hear about us?:

Yelp
Google
Insurance Provider
Family/Friend
Other

If Family/Friend, their name:

 

Patient Name 1: *

Patient Name 2:

Patient Name 3:

Emergency Contact (Please list contact other than parent/guardian): *

Relation to patient?: *

Home phone: *

 

Parent/Guardian Information

Parent Name 1: *

Relation to Patient: *

Date of birth: *

  

Home phone: *

Work phone:

Cell phone:

Email: *

 

Mailing address: *

City: *

State: *

Zip: *

Employer:

Occupation:

Preferred way to contact: *

Home phone Cell phone Email Work phone  

 

Parent Name 2:

Relation to Patient:

Date of birth:

  

Home Phone:

Work Phone:

Cell Phone:

Email:

 

Mailing Address:

City:

State:

Zip:

Employer:

Occupation:

Preferred method of contact:

Home phone Cell phone Email Work phone  

 

Patient Insurance Information

Primary Insurance Provider:
(Bring copy of card to appointment)

Insurance Phone Number:

Subscriber (Legal Name):

Date of birth:

  

Employer:

Relationship to Patient:

Insurance ID#:

Insurance Group#:

Insurance Effective Date:

 

Secondary Insurance Provider:
(Bring copy of card to appointment)

Insurance Provider Phone:

Subscriber (Legal Name):

Date of birth:

Employer:

Relationship to Patient:

Insurance ID#:

Insurance Group#:

Insurance Effective Date:

 
 
 

It may take a moment to submit your information. Please wait for a confirmation message.

 
 
invisible spacer graphic invisible spacer graphic
Pham request apt button

Pham kids corner button

Pham testimonials button

Our Doctors:
Hai Pham, DMD
Jenette Intrachat, DDS
Grace Shao-Chiu Chen, DMD, MS
Jessica Irwin, DMD
Edward Pham, DMD

TOP DENTIST, Portland Monthly

Dr. Pham was featured in Portland Monthly, chosen
as one of the Top Dentists, Pediatric Dentistry, 2011, 2012, 2013, 2014, 2015.
Proud Member
ada logo AAPD logo OAPD logo 1 PFA logo image of of dimensions 200 wide by 200 high AAP Logo image of of dimensions 300 wide by 150 high AAO Logo
Hospital Privileges
Dr. Pham has hospital privileges at:

Hillsboro

Hi5 Dental
Dentistry for Kids
3075 SE Century Blvd Ste 109
Hillsboro, OR 97123
Phone: (503) 642-1535
map
pham dotted line
Portland

Hi5 Dental
Orthodontics
2375 SW Cedar Hills Blvd,
Portland, OR 97225
Phone: (971) 713-3899
map
pham dotted line
Beaverton

Hi5 Dental
Pediatric Dentistry
14671 SW Millikan Way
Beaverton, OR 97006
Phone: (503) 644-4749
map
pham dotted line
Office Hours

Monday - Thursday: 8am to 5pm
Friday: 8am to 12pm

FB btn   Visit Hi 5 Dental on Google+   Yelp Square Button for Bottom
smile reminder round

Home  | Meet The Doctors  | Dentistry for Kids  | Office Info  | Dental Reviews  | New Patients  | Referring Doctors  | Locations  | Hai Pham, DMD  | Jenette Intrachat, DDS  | Grace Shao-Chiu Chen, DMD, MS  | Jessica Irwin, DMD  | Edward Pham, DMD  | Insurance  | Dental FAQ  | First Visit  | Preventive Care  | Treating Decay  | Early Orthodontics  | Sports & Mouthguards  | Special Needs  | Sedation Dentistry  | Dental Emergencies  | Hi5 Dental in Hillsboro  | Hi5 Dental in Cedar Hills  | Hi5 Dental in Beaverton




Hai Pham DMD - Hi5 Dentistry for Kids | hi5dental.com | (503) 642-1535
2375 SW Century Blvd, Hillsboro, Or 97225


 

 

Copyright © 2011-2024 Hai Pham DMD - Hi5 Dentistry for Kids and WEO Media (Touchpoint Communications LLC). All rights reserved.  Login
Hai Pham DMD - Hi5 Dentistry for Kids, 2375 SW Century Blvd, Hillsboro, Or 97225, (503) 642-1535, hi5dental.com, 9/16/2024, Page Keywords: Board Certified Pediatric Dentist Beaverton OR,


Go to Mobile website