Please fill out the form to register as a new patient. 

Once you are done with the form, please verify that all is spelled correctly and all of your information is thoroughly filled out. If you get an error message, it means that you have left a critical piece of information off of the digital form. 

Patient Name *
Patient Name
Today's Date *
Today's Date
Patient's Birthday *
Patient's Birthday
Home Address *
Home Address
Home Phone
Home Phone
Work Phone
Work Phone
Cell Phone
Cell Phone
Business Address
Business Address
SPOUSE INFORMATION
Spouse Name
Spouse Name
Spouse's Birthday
Spouse's Birthday
Work Phone
Work Phone
Business Address
Business Address
PRIMARY INSURANCE CARRIER
Insurance Co. Telephone
Insurance Co. Telephone
EMERGENCY CONTACT
Home Phone
Home Phone
Work Phone
Work Phone
Cell Phone
Cell Phone
PATIENT AGREEMENT
The information I have provided is complete and accurate to the best of my knowledge. I consent to whatever procedures are deemed necessary to diagnose my oral condition. I agree to be responsible for payment of all services rendered. I understand that if I have I insurance coverage, they will not pay for the entire balance and that I am responsible for payment fo the remainder of the balance. I authorize a credit check should I ask for credit.
I have read and understood. *
Today's Date *
Today's Date