See you Soon!

(808) 633-6931 text/call

PATIENT FORMS

APPT FORM

Emergency and Telehealth appointments available 24/7, depending on dental team availability.

Please do not come to the office until the time of your appointment has been confirmed. Thank you.

Name of Patient

First Name

Last Name

Phone Number (that can receive text)

Other than Canada, we are unable to call/text international numbers.

(###)

###

####

Email Address

Date of Birth

YYYY

1. Are you a visitor or Maui resident?

2. Location on Maui (address or name of lodging)

3. Have you seen us before?

4. Is this a dental emergency?

5. Message/Reason for Visit/Preferred Day & Time:

7. Please text a photo of your ID and photo of your tooth (if applicable) to (808) 633-6931 (new patients)

8. Please click on blue button "PATIENT FORMS" above and complete medical history and consents.

9. Do you agree to the following fees? (Please note we are unable to accept dental insurance but we are happy to provide you a claim form for reimbursement):

Limited examination: $495 Telehealth consultation: $395-595 Dental Xray: $100-200 Dental cleaning (done by the doctor): $395. Treatment fees: Additional fee quoted at time of visit (usually between $495-$2995, depending on treatment needed) Emergency Fees are additional

Permission to send SMS/Text Message

Do we have your permission to communicate via SMS/text? Please reply “Yes” to opt in, or “No” to opt out.

Payment Type (*Not* charged until appointment is confirmed and completed)

Name on Credit Card

First Name

Last Name

Amount of Payment

Credit Card Type (No AMEX, No Discover)

Credit Card Number

Expiration Date

Billing Address (Street address)

Billing Address (City, State, Zip code)

MAKE A PAYMENT

Has our office messaged you regarding a deposit or payment? Please do *not* make a payment or come to the office until our office has been in contact with you. Thank you.

Name of Patient

First Name

Last Name

Phone

(###)

###

####

Payment Type (*Not* charged until appointment is confirmed and completed)

Name on Credit Card

First Name

Last Name

Amount of Payment

Credit Card Type (No AMEX, No Discover)

Credit Card Number

Expiration Date

3 or 4 Digit Code

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Message

Please text a picture of your photo ID to (808) 633-6931. Thank you.

HOURS

Our office hours are variable, depending on our schedule.

After Hours: Open for Emergencies (may incur additional fees)

AFTER HOURS EMERGENCY SERVICE AVAILABLE

Forms - Hospital Patients Only

DIRECTIONS

Get Directions

Directions to Maui Dental Group (Kihei, Maui location):

Please do not come to to the office until your appointment has been confirmed. Mahalo!
Address: 56 Ehiku Street Suite 2, Kihei, HI 96753
(within Hale Mahaolu complex)
Serving all of Maui: Kihei, Wailea, Kahului, Wailuku, Haiku, Lahaina

Driving Directions: 

Our office is located in the Hale Mahaolu Ehiku residential complex in Kihei. Please note parking is limited, so please park in the gravel lot.

Driving Directions: Our office is located in the Hale Mahaolu Ehiku residential complex in Kihei. Off of South Kihei Road or Piilani Hwy - Turn onto Welakahao St. -Then turn onto Liloa St. (past the large church, Hope Chapel) -Go straight until you see the wall with signs “Maui Dental Group” and “Hale Mahaolu Ehiku”. Turn left at the wall and please park in the gravel lot on your left side. Walk past the “Harry & Jeanette Weinberg Center” and turn right into the atrium. Our reception office is on the left side of the atrium

Please text us if needed and we can direct you to the clinic. Our number is 808-633-6931.

Contact/Forms

See you Soon!

(808) 633-6931 text/call

APPT FORM

MAKE A PAYMENT

DIRECTIONS