Patient Registration
Below is the link to our new patient intake forms. These forms are required for all new patients and for previous patients if it has been more than one year since your last visit in our office. It is your responsibility as a patient to provide us with the information needed in order to properly facilitate your care.
PLEASE BE SURE TO INCLUDE THE FOLLOWING INFORMATION AT MINIMUM BEFORE SUBMITTING FORMS:
- FULL NAME (IF YOU HAVE INSURANCE, IT MUST MATCH ACCORDINGLY)
- MAILING ADDRESS
- DATE OF BIRTH
- ACCOUNT GUARANTOR INFORMATION (IF DIFFERENT FROM PATIENT)
- DENTAL INSURANCE INFORMATION (WE DO NOT GATHER THIS INFORMATION FROM REFERRING OFFICES)
- SUBSCRIBER’S FULL NAME
- SUBSCRIBER’S DOB
- MEMBER ID (OR SSN IF NOT GIVEN AN ID)
- DENTAL INSURANCE COMPANY NAME
- DENTAL INSURANCE MAILING ADDRESS
- HEALTH HISTORY / ALLERGIES
- AUTHORIZATION SIGNATURES
