Registration Form

To effectively process your intake paperwork, we must have a copy of your Insurance Card front and back and Driver's License.

If you do NOT have dental insurance, please mark the corresponding option below.

Please ensure you have these available before completing this form - you can upload pictures of them from your mobile device/phone by clicking on the upload fields below. **Please note - if you have both a primary and secondary insurance, be sure to upload both of them in the designated sections for each.

Upload Primary Dental Insurance Card

Front of card:

Back of card:

Primary Dental Insurance Information

Policyholder Name

Policyholder Date of Birth

Policyholder Social Security #

Employer of Insurance Holder

Employer Phone of Insurance Holder

Insurance Company

Insurance Company Phone

Policy number

Group number

Do you have secondary insurance?

Yes

Patient Registration Form

Upload Primary Dental Insurance Card

Primary Dental Insurance Information

Upload Secondary Dental Insurance Card

Secondary Dental Insurance Information

Upload Driver's License

Patient Information

Emergency Information