Adult Registration Form

Patient Information

Patient Birth Date


Spouse / Partner Information

Birth Date

Emergency Contact Information


Insurance Information

Primary Insurance Company
Birth Date

Secondary Insurance

Birth Date

Dental History

If yes, when?

Have you ever had an injury to (select all that apply)

Do you currently have or ever had any of the following habits (check all that apply)

 Medical History

Are you currently being treated by a physician?
Date of Last Visit


Check if you have or have ever had any of the following:


I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.

I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.

Today's Date