770-926-2784
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Request Appointment
770-926-2784
Follow
Follow
Follow
Follow
Home
About Us
Meet the Doctors
Meet the Staff
Meet Dental Hygienists
Meet Dental Assistants
Services
Dental Implants
All-on-4® Dental Implants
Teeth Whitening
Cosmetic Bonding
White Composite Fillings
Crowns
Bridges
Dentures
Invisalign
Professional Dental Cleanings
Dental Hygiene
ADA Toothflix
Before and after
Online Forms
New Patient Forms
Formularios para Nuevos Pacientes
Contact Us
Se habla español!
Request an Appointment
Patient Registration Form
Patient Registration
"
*
" indicates required fields
Step
1
of
2
50%
ID
*
Chart ID
Name
*
First
Middle Initial
Last
Preferred Name
First
Patient is:
Responsible Party
Policy Holder
Responsible Party:
(if someone other than the patient)
Name
First
Middle Initial
Last
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Home Phone
*
Work Phone
Cell Phone
Birth date
*
MM slash DD slash YYYY
Social Security #
Drivers Lic# & State
Responsible Party is also Policy Holder for Patient
Primary Policy Holder
Secondary Policy Holder
Patient Information
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Home Phone
*
Work Phone
Cell Phone
Sex
*
Female
Male
Marital Status
*
Married
Single
Divorced
Separated
Widowed
Birth date
*
MM slash DD slash YYYY
Social Security #
Drivers Lic# & State
Email
*
I would like to receive email correspondences
Patient Information (section 2)
Employment Status
*
Full Time
Part Time
Self Employed
Retired
Unemployed
Student Status:
Full Time
Part Time
Preferred Pharmacy
Pharmacy #
Emergency Contact
*
Emergency #
Primary Insurance Information
Name of Insured
*
Relationship to Insured
*
Self
Spouse
Child
Other
Member ID
Group ID #
Insured Social Security #
*
Insured Birth date
*
Employer
*
Insurance Company
*
Secondary Insurance Information (If Applicable)
Name of Insured
First
Relationship to Insured
Self
Spouse
Child
Other
Member ID
Group ID #
Insured Social Security #
Insured Birth date
MM slash DD slash YYYY
Employer
Insurance Company
