New Patient Registration

Personal Information

Tell us about yourself

First Name *

Required

Last Name *

Required

Preferred Name

Date of Birth *

Required

Gender

Street Address *

Required

Apt/Suite

City *

Required

State *

Required

ZIP *

Required

Cell Phone *

Required

Home Phone

Work Phone

Email *

Valid email required

Preferred Contact Method

Phone Email Text

Emergency Contact

In case we need to reach someone

Contact Name *

Required

Relationship

Phone *

Required

Insurance Information

Your dental insurance details

Do you have dental insurance?

Insurance Company *

Member ID *

Group Number

Subscriber Name

Subscriber DOB

Relationship to Subscriber

Dental History

Tell us about your dental background

Reason for Today's Visit *

Previous Dentist

Last Dental Visit

How would you rate your dental anxiety?

No anxietySevere anxiety

Any specific dental concerns?

Consent & Acknowledgment

Please review and sign below

HIPAA Notice of Privacy Practices: I acknowledge that I have been offered a copy of the Notice of Privacy Practices which describes how my health information may be used and disclosed. I understand that I may request a copy of this notice at any time.

Consent to Treatment: I voluntarily consent to dental treatment and procedures as recommended by my dental provider. I understand that no guarantees have been made to me regarding the outcome of any treatment.

Financial Responsibility: I accept responsibility for all charges for dental services provided to me or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. I authorize my insurance benefits to be paid directly to the dental office.

I acknowledge the HIPAA Notice of Privacy Practices * I consent to dental treatment as recommended * I accept financial responsibility for services rendered *

Digital Signature *

Sign with your mouse or finger

Date

Printed Name

✓

Registration Complete!

Thank you for completing your new patient registration.

Our team will review your information before your appointment. Please arrive 10 minutes early and bring a valid photo ID and your insurance card.

Questions? Contact us at MyDentalPMS@gmail.com

New Patient Registration

Personal Information

Emergency Contact

Insurance Information

Medical History

Dental History

Consent & Acknowledgment

Registration Complete!