Before your first visit, we'll need to learn more about you. For your convenience, we've developed an easy to use, secure online form. See below for more information. Your initial exam will last approximately one hour.

Patient Information Form

Before your first visit you will need to fill out our Patient Information form. Our online form provides a convenient and secure way for you to provide us with your information. In order to ensure the security of your personal information, we ask that you register as a user first. This will give you access to the password-protected form. Here are the steps to submit your information:

User Login
Don't have an account yet? Click here to set one up.



1. Set up a user account. If you've already set up an account, login using the form on the right (you'll see your name if you're already logged in).

2. Gather all the information you'll need to complete the Patient Information Form. Here's a list:

  • Patient Information - We'll ask for your standard contact information and an emergency contact.
  • Medical History - For this section, you'll need the name and contact info for your doctor and be ready to answer a series of questions related to your health.
  • Dental History - We'll need the name of your dentist and some information about your teeth.
  • Responsible Party - Please provide us with the name and contact information for the person responsible for paying your bill.
  • Insurance Information - Be ready with your insurance policy group number.

3. Click on the button below to open the form and begin filling out your information. The form is long, so give yourself some time. Do not close the window once you've begun the process, or you'll loose the data and will have to start over. Please do your best to be thorough and complete with your information -- this will expedite the process during your first visit. Note: If you choose not to register, you'll need to use this form instead -- print each page and bring them with you to your first appointment.

If you are using Internet Explorer version 6.0 or earlier, you'll need to upgrade to the latest version before using the form. Click here to get Internet Explorer 8

 

Open the Form
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