Patient Registration

Patient Registration Form

Fill out the form below and we will contact you during our working hours.

    Date of Birth
    How do you want to be addressed
    Marriage Status
    Parent/Guardian (for minor patient)

    Other family member in this office
    Whom may we thank for this referral
    Who responsible for this account

    Do you have any dental coverage?
    Do you have second coverage thru another family member?

    Consent to Release
    I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I authorize the release of any information concerning my (or my child's) health care, advice, and treatment provided for the purpose of evaluating and administering claims for insurance benefits.
    I authorize release of any information concerning my (or my child's) health care, advice and treatment to another dentist.
    I hereby authorize payment of insurance benefits directly to the dentist or dental group, otherwise payable to me. I understand that my dental insurance carrier or payor of my dental benefits may pay less than the actual bill for services. I understand I am financially responsible for payment of services not paid, in whole or in part by my dental care payor.
    I attest to the accuracy of the information on this page and my medical and dental history.

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