New Patient Registration

Complete our new patient registration form to get started

New Patient Registration Form

Please fill out the form below. All fields marked with * are required.

Patient Information

Today's Date *

Gender *

First Name *

Last Name *

Date of Birth *

Social Security # *

Street Address *

City *

State *

ZIP *

Home Phone

Cell Phone *

Work Phone

Email Address *

Patient Employer/School

Occupation/Major

Whom may we thank for referring you?

In case of emergency who should be notified? *

Emergency Phone *

Person responsible for the account *

Relation to patient *

Primary Insurance

Policyholder First Name

Last Name

D.O.B

Social Security #

Street Address

City

State

ZIP

Dental Insurance Company

Subscriber's Employer

Insurance Co. Address

Insurance Co. Phone #

Group or Policy #

Subscriber ID#

Secondary Insurance (Optional)

Policyholder First Name

Last Name

D.O.B

Social Security #

Street Address

City

State

ZIP

Dental Insurance Company

Subscriber's Employer

Insurance Co. Address

Insurance Co. Phone #

Group or Policy #

Subscriber ID#

General Treatment & HIPAA Consent

I give my consent that I, or my above named dependent(s), receive dental treatment, education, and any other dental related services. I acknowledge the administration of anesthetics, as may be considered necessary or advisable by the dentist. I acknowledge that I have been informed of, and I understand the recommended treatment. I acknowledge that I have not received guarantees, warranties, or representations concerning the results of the treatment or procedures. I accept the responsibility of the following for paying my above named dependent(s) and I agree to pay all charges incurred for services rendered. I agree to pay all costs of collection including attorney fees and court costs. I authorize the release and or exchange of information, including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and/or health practitioners. I authorize the use of this signature on all insurance submissions. I understand that I am financially responsible for all charges whether or not they are covered by insurance. I authorize payment of insurance benefits directly to the dentist or dental group. I have read the foregoing and I understand and agree to the provisions set forth in the notice. It is impossible to eliminate all risk of contracting an infectious disease while receiving dental care. I have the right to withdraw this consent at any time. I will still be responsible for the unpaid balance and for any complications arising from treatment already rendered.