PDX Center for Dentistry
View and complete PDX Center for Dentistry's new patient forms

(503) 928-5903
511 SW 10th Ave Suite 1101 Portland, OR 97205
PDX c4d subpage logo 11.12.19
Patient Screening Form
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¡El Doctor habla español!
Por favor llámenos al 503-928-5903 para hacer una cita con Doctor Seo.

Appointment Commitment Agreement

We respectfully request a 2-business day notice for cancellations or rescheduling an appointment. This allows enough time to contact our patients waiting for treatment.


If you are unable to allow a 2-business day notice, we will notate the account with a Short Notice Cancellation warning. If any additional Short Notice Cancellations occur, we will apply a Cancellation fee to the account. This fee is $75 for Hygiene hour and $150 for a Doctor hour.


We are 100% committed to our patients and respectfully request the same in return.


Electronic Signature

Patient First Name: *

Patient Last Name: *

Date: *

The person filing out form is: *

If Representative, Representative';s Name:


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

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PDX Center for Dentistry

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Samuel Seo, DMD

PDX Center for Dentistry

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PDX Center for Dentistry | www.pdxdentistry.com | (503) 928-5903
511 SW 10th Ave, Suite 1101, Portland, OR 97205