Register with Us

Please fill out the form below to register as a new customer.

The information will help enter your information into our system so you will have less paperwork on your first visit.

Registration Information

    Patient Information

  • We are pleased to welcome you to our practice. Please take a few minutes to fill out his form as completely as you can. If you have questions, we will be glad to help you. We look forward to working with you in maintaining you dental health.
  • Primary Insurance

  • Fill out address, phone and employment if person responsible for account is different from patient. All other insurance information is required.
  • We accept most forms of insurance. Be sure to contact our office to check if your insurance is accepted. (920)733-4740.
  • Additional Insurance

  • Dental History

  • Medical History

  • I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for serviced rendered. I authorize the use of this signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether ot not paid by insurance. My typed signature and date will be my electronic signature for this information.

Verification