Patient Forms, Map and Directions to Rockville Office
Welcome to our practice, in preparation for your initial consultation we recommend that you plan to arrive 15 minutes early for your scheduled appointment so you have time to complete your forms including your medical history. In addition, please bring any recent x-rays or dental records with you.
We are so happy that you are entrusting your care to Jay Samuels, DDS. We are committed to making sure that our friendly and professional environment ensures you a relaxing and successful dental experience. If you have any concerns or apprehension about dental care, Dr. Samuels' can provide you with a cutting-edge, non-sedating technology that will calm your nerves and help you relax (while at the same time, giving you a respite you deserve).
If you have are interested in finding out more about this state-of-the-art technology and our other advanced techniques in patient care for you and your family, please email us at [email protected]. And, in this world of 24/7 communication-choices, please let us know the best way to follow up, i.e. email, phone, cell, office and the best time & day for us to contact you.
Finally, we are excited about our new blog Dental Notes and social media presence. Please be sure to "like us" on Facebook by clicking here.
Thank you for visiting our site and we look forward to meeting you.
Mission Statement
Our practice is working together to realize a shared vision of uncompromising excellence in dentistry.
To fulfill this mission, we are committed to:
- Listening to those we are privileged to serve.
- Earn the trust and respect of patients, profession and community.
- Exceed your expectations.
- Ensure a creative, challenging and compassionate professional environment.
- Strive for continuous improvement at all levels.
Patient Forms
Please print and fill out these forms so we can expedite your first visit:
Coming Soon
In order to view or print these forms you will need Adobe Acrobat Reader installed. Click here to download it.
What To Expect
Being well-prepared for your appointment will ensure that the doctor has all of the needed information to provide the best possible care for you. It also will help relieve any unnecessary anxiety you may be feeling. Educate yourself on your symptoms by reviewing the content on this Web site. Also, take some time to review our staff page and familiarize yourself with the doctors. We look forward to your first visit.