Pediatric Dentistry

Patient Registration

Staff members are available to assist you through the patient registration process.

For your convenience and to make the appointment as smooth as possible for your child, you may either:

  • complete registration forms below or
  • a registration packet will be mailed to you prior to the appointment.

We ask that you complete the forms and bring them with you for the first appointment.

Insurance information and documents are required to make registration complete.

A parent or legal guardian must accompany the child for the first visit.

Please complete and print the Online Registration Forms below and bring them to your appointment.

Registration Form

Medical and Dental History

Privacy/HIPAA Form

Child Registration Form (optional)

Parental Authorization for Alternate/Proxy Form (optional)

Previous Records Request Form (for transferring patients)

Please review our Privacy Policy

You will need Adobe Acrobat Reader to view our forms.
Please download the free Acrobat Reader from Adobe's web site if it is not already installed on your system.

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