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Call us on +386 5 640 4040 Modern Dental Studio

New patient form

First and Second Name

Telephone number

Email (required)

Full address


Date of Birth

Insurance paySelf paid visit

Do you already have your dentist?

Last visit at the dentist was?

Short summary of past problems

Reason for today’s visit

Attach a photo, document,…

Are you scared by dentists?


Payments methods

If needed, you can pay with / or just / we accept
Visa American Express Maestro Paypal Diners Card Master Card

For more more informations about our payments options call us on

386 5 640 40 40 or write us on

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