Online Patient Registration Form

Please correct the errors described below.

CONTACT INFORMATION

MEDICAL INFORMATION

Women Only:

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

      UPLOAD SECONDARY INSURANCE CARD

        Please upload a file
          Please upload a file

          SECONDARY INSURANCE COMPANY INFORMATION

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


          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 form 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 ENITRE registration form.

          Your information will be encrypted.

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