New Patient? Please fill in the form below and submit it to us prior to making an appointment. Doing so will save you time. You can also call our office at (951) 485 2800 or email Dr. Karna at hakdds@verizon.net The fields marked with (*) are required fields. * Today's Date:  * required * Last Name:  * required * First Name:  * required   Middle Initial:   Prefix: Mr. Mrs. Miss Ms.   Marital Status: Single Married Divorced Separated Widowed * Street Address: * City:  * required * State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington West Virginia Wisconsin Wyoming * Zip Code:  * required * Home Phone:  * required   Birth Date:   Sex: Male Female   Social Security No.:   Occupation: * Employer:  * required   Employer's Address:   Employer's City:   State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington West Virginia Wisconsin Wyoming   Zip:   Employer Phone No.: * Is patient covered by insurance? Yes No   Please indicate primary insurance:   Subscriber Name:   Subscriber SSN:   Birth date:   Group No.:   Policy Number:   Co-Payment $: * Patient's relationship to subscriber: Self Spouse Child Other   Secondary insurance (if applicable):   Subscriber's Name:   Group No.:   Policy No.:   Relationship to Patient: Self Spouse Child Other   In case of emergency, name of local friend or relative (not living at same address):   Relationship to patient:   Home Phone:   Work Phone:   Referred By: Search Engine Outside Ad Referred by a friend Referred by a family member 1-800-Dentist Yellow Pages Other   Other Family members seen here:

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