Patient 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.

Do you have Dental insurance?

Upload Driver's License

Patient Information

Emergency Information

Name, Address, & Telephone of a relative not living with you: