Online Forms

You may preregister with our office by filling out our secure online Patient Registration Form. Please have your insurance and personal information ready before you fill out the form; the system¬†will not be able to save the information for you to continue on a later time. After you have completed the form, please make sure to press the “Complete and Send” button at the bottom to automatically send us your information.

The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

New Patient Registration

Acknowledgement of Receipt of Notice of Privacy Practices

Authorization for Use or Disclosure of Patient Information

For the following preventive care visits parents or guardians can complete the following form:

Patient Update Form

Parents or guardians who want to authorize somebody else to bring the child need to complete the following form:

Minor Consent Form

Sedation Consent Form

Sedation Consent

Let us help you introduce your child to dental health!

Call us: 405-348-5757