patient registration form

Step 1 of 2

Patients Name *

First

Last

Birthdate//

Sex

Male
Female

Patient email address

Responsible Party (if someone other than the patient)

Parent or Guardian Name *

First

Last

Parent or Guardians Email Address

Home

Work

Mothers Cell Phone

Fathers Cell Phone

Address

Address Line 1

City

State

Zip Code

Patient address if different from above

Address Line 1

City

State

Zip Code

What is your preferred method of communication (please check preferred options)

Text Message
Voice Message
Email

HIPAA Compliance Agreement

Signature

Date

Authorization for Release of Information

Signature

Date

Dentist Name

Dentist Phone

Dentist Address

Address Line 1

Address Line 2

City

State

Zip Code

Orthodontist

Orthodontist Phone

Orthodontist Address

Address Line 1

Address Line 2

City

State

Zip Code

Medical Doctor

Medical Doctor Phone

Medical Doctor Address

Address Line 1

Address Line 2

City

State

Zip Code

Other Health Care Provider

Other Health Care Provider Phone

Other Health Care Provider Address

Address Line 1

Address Line 2

City

State

Zip Code

Website