Health History Form

Printable Patient Registration Form

You may register with our office by filling out our printable Patient Registration Form. After you have completed the form, please make sure to bring it with you at the time of your appointment

Technical Note:

PC Users
Our online form uses Adobe Acrobat Reader 5 or greater plug-in to conveniently print the form from home or work. Please download the free plug-in from Adobe’s web site if it is not already installed on your system. It is important that you have at least Version 5 of the plug-in to successfully use our form.

Mac Users
You must open and print the form in a Safari Browser with the latest Mac operating system. It is also important to have the latest version of Adobe Acrobat Reader on your computer in order to print your form correctly. Please download the free plug-in from Adobe’s web site.

Are You Ready to Enhance Your Smile?

Contact us with any questions or to schedule an appointment to reclaim your smile today!

Call us: 845-947-1117