Patient Registration

 

Please assist us by providing the following information at the time of your consultation:

• Your referral slip from your dentist and any X-rays if applicable.

• A list of medications you are currently taking.

• If you have dental insurance, please have this information available at the time your appointment is made. This will save time and allow us to expedite processing your claims.

• Your completed registration form

• Drivers License or Photo ID

 

IMPORTANT: A parent or guardian must accompany all patients under 18 at the consultation visit.

• Please alert our office if you have a medical condition that may be of concern prior to your procedure (i.e. diabetes, high blood pressure, artificial heart valves and joints, rheumatic fever, etc.) or if you are on any medication (i.e. heart medications, aspirin, anticoagulant therapy, etc.) or require medication prior to dental cleanings (i.e antibiotics, for pre-med.)

 

 

 

 

You may open this form in Adobe Reader to enter the data for printing. Then bring it to your appointment or Fax to 316-681-0346. For your safety, please do not use email for confidential information.

 

 

Click here for our Privacy Practices

 

Forms are in pdf format and require free Adobe Reader.  If you do not have Adobe Reader, click here.