New Dental Patient Registration Form

Ted T. Sakamoto, D.D.S. 615 Piikoi St, Suite 801 (808) 593-0835

Please correct the errors described below.

Patient Information

Parent or Guardian Information (Only If Patient is a dependent)

Primary Dental Insurance Information (If applicable)

Secondary Dental Insurance Information (If applicable)

Dental History

Medical History

Your Smile

By submitting this form, I affirm that it has been completed to the best of my knowledge and I authorize the disclosure of my dental records for the purpose of treatment, payment and healthcare operations as outlined in the HIPAA privacy practices document provided by our office.

Your information will be encrypted.