Patient Registration Form

Patient Information

*All fields required

Salutation

First Name

This field is required.

Last Name

This field is required.

Date of Birth

This field is required.

Registering for a child?

Yes

This field is required.

Contact Information

This field is required.

Home Phone

This field is required.

Cell Phone

This field is required.

Work Phone

This field is required.

Address

Street Address

This field is required.

City

This field is required.

State

This field is required.

ZIP Code

This field is required.

In case of emergency, please notify:

Name

This field is required.

Relation

This field is required.

Home Phone

This field is required.

Cell Phone

This field is required.

Work Phone

This field is required.

Contact Options

I prefer appointment reminders by

Phone

SMS (TEXT)

This field is required.

Whom may we thank for referring you?

This field is required.

Are any other members of your family patients at our practice?

Yes

This field is required.

Insurance Information

Yes, insurance applies to me

No, insurance does not apply to me

This field is required.

Dental History

Do you have any specific dental concerns? Please list:

This field is required.

When was your last dental appointment?

This field is required.

How often do you see the dentist?

This field is required.

Is there anything about the appearance of your teeth that you would like to change?

This field is required.

Have you ever whitened (bleached) your teeth?

Yes

Not Sure/Maybe

Do you feel uncomfortable or self-conscious about the appearance of your teeth?

This field is required.

Have you been disappointed with the appearance of previous dental work?

I agree to receive emails with related information and updates.

Patient Information

Contact Information

In case of emergency, please notify:

Contact Options

Insurance Information

Medical History

Dental History