Name:
Address:
Referral Person:
Email:
Phone:
Preferred Time:
  

Preferred Date:

     
 
     
  Schedule An Appointment
Please complete the form below or call 208.466.2456
to schedule an appointment.  Office Hours


  Mon - Thurs 7:00am-7:00pm
 Friday 7:00am-5:00pm
 Saturday 7:00am-1:00pm
 

Information about the appointment:

  Patient First Name:

  

  Patient Last Name:

  

  Responsible Party (if not patient):

  

  Patient Email Address:

  

  Patient Phone Number:

  

  1st Choice Appointment Date:

  

  1st Choice Appointment Time:

  

  2nd Choice Appointment Date:

  

  2nd Choice Appointment Time:

  
 I am interested in Sedation Dentistry
 I am a New Patient to Nampa Smiles.
First Time Appointments
 
In order to add convenience and speed to the process for new patients of Drs. Kim Keller and Amelia Justin, we are providing the necessary forms available for download and completion at home. Print them and fill them out at your convenience before coming by the office. If you have any questions, concerns or want us to send you the forms by mail, please feel free to Contact Us.
 

Patient Information Form

Health History Form
If you unable to view PDF files on your computer, you can download Adobe Acrobat Reader free directly from Adobe.