New Patients

Our office accepts new patients. A referral from a dentist is not required. We receive many referrals from our loyal patients of record.

To help us treat you safely, we request that you complete the patient information form. To save you time, you may download our online patient information form, print it, and fill it out at your convenience before your appointment. This PDF form can be opened with Adobe Acrobat Reader 7.0 or later (free if you don’t already have it). If you e-mail the form, we will ask for your signature when you come to the office.


You have 2 options when filling out the new patient form.


Option 1.  Print the form and complete it. FAX form to 909-981-2149 or bring it to the office.
Option 2.  Fill out the form online. Print as a PDF. E-mail to or FAX to 909-981-2149.

*When viewing this form on iOS, download to the Files app and then fill in the fields.

Thomas J. Kepic, DDS, MSD
250 East 7th St., Suite D
Upland, CA 91786

Phone: 909-982-4169