Online Patient Registration Form

Please correct the errors described below.

CONTACT INFORMATION

MEDICAL INFORMATION

Women Only:

PATIENT BILLING AND DENTAL INSURANCE INFORMATION

UPLOAD DENTAL INSURANCE CARD

    Please upload a file
      Please upload a file

      DENTAL INSURANCE COMPANY INFORMATION

      *** If you do not have dental insurance to cover Endodontic treatment, please proceed to FINANCIAL AGREEMENT ***

      PRIMARY INSURANCE SUBSCRIBER INFORMATION

      SECONDARY INSURANCE SUBSCRIBER INFORMATION

      AUTHORIZATIONS

      FINANCIAL AGREEMENT

      Please read and print the following for your records:
      Notice of Privacy Practices
      Risks of Treatment

      ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND RISKS OF TREATMENT

      I have reviewed the information on this registration and it is accurate to the best of my knowledge

      DISCLAIMER: By typing your name below, you are signing this ENTIRE registration form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this ENTIRE registration form.

      Your information will be encrypted.

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