Please enter your name First, Middle Initial and Last
Please select Male or Female
Please select your current status in your family chart
For billing purposes, please enter your Social Security number. Dependents under the age of 18 yrs are not required to provide a Social Security number.
For billing purposes, please provide your date of birth.
Please enter whom reffered you to us or if you found us with an advertisement source.
Please enter the e-mail you would like us to use to set up your personal patient portal.
Please enter your primary phone number
Please enter your address in the format:
City, State Zip
Please enter your primary dental insurance information. Include: Name of Insurance Company, Insurance Phone Number, Name of Subscriber, Date of Birth of Subscriber, Group Number and Relationship to Subscriber. If you don't have any insurance, type "NONE".
Please enter your secondary dental insurance information.Include: Name of Insurance Company, Name of Subscriber, Date of Birth for Subscriber, Group Number and Relationship to Subscriber. If you don't have a secondary dental insurance, type "NONE".
Please enter your primary medical insurance information, if you don't have any medical insurance please type "NONE".
Please select all the conditions that you currently have or have been diagnosed in the past.
Are you currently under the care of a physician?
Name of Physician?
What is the current condition that you are being treated for? List any Medications you are currently taking.
Please enter your preferred pharmacy for prescriptions. Include: Pharmacy Name, Phone Number and Address or Intersection. If you do not have a preferred pharmacy, type "NONE".
What allergies do you currently have or been diagnosed in the past?
Note: A credit card is required for future charges, including broken appointment fees.
I hereby understand that I am responsible for all appointments that I schedule, hold or request in this office and that in the event that I do not provide a 48hr notice to the office in an attempt to reschedule or cancel an appointment, that I will incur a broken appointment charge. I also understand that if the appointment reserves a significant amount of time with my doctor, that I may be responsible for additional charges that the office deems fair in the circumstances. If I have an emergency that is unavoidable, I can request this to be waived upon documentation of the emergency on a case by case basis.
This form is a protected document in the handling of your chart, we request that you acknowledge your agreement with this form.