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Patient Registration Form

Patient Information

Please provide the patient's name.
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Please provide a valid date of birth in the following format (mm/dd/yyyy)
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Employment Information

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Other Information

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Payment Information

Please provide the name of the person responsible for the account.
Please provide a method of payment.

Dental Insurance: 1st Coverage

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Dental Insurance: 2nd Coverage

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Consent Statements

I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care.

I consent to the dentist's use and disclosure of my records (or my child's records) to carry out treatment, to obtain payment, and for those activities and health care operations that are related to treatment or payment.

I authorize payment directly to the dentist or dental group of insurance benefits otherwise payable to me.  I understand that my dental care insurance carrier or payor of my dental benefits may pay less than the actual bill for services, and that I am financially responsible for payment in full of all accounts.  

I agree to be responsible for payment of services not paid by my dental care payor. 

You must check the consent box to submit this form online.
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Please provide an electronic signature.
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