Registration Form

Fill out our registration form to bypass the waiting room on the day of your appointment! If you have any questions, call us at 806-780-4911.

Filling out this form this allows our staff to provide pre-registration as well as shorter waiting times! The information you provide us with will help to create a customized visit that will suit your needs. Your information will always remain confidential.

PLEASE NOTE: Any information in the following form that you elect not to provide must be provided on the date of your appointment. Not providing information before your appointment will increase check-in time as this information will have to be put into our system upon arrival. Our office staff will review your pre-appointment registration information and let you know what we lack when you arrive.

If you have any questions about the form, please don’t hesitate to call us at 806-780-4911.

* = Required Fields

    Dental Information

    Are you aware of any particular dental problem?

    Personal Information

    Date of Birth:

    Is patient:

    Home Address:

    Employer Information

    Insurance Information

    Health History

    Please check if you have or have ever had: (Required for treatment)

    Are you pregnant?

    Do you have any allergies to drugs or medicines? (please list them if so)

    Do you have any other health problems? (please list them if so)

    Are you taking any pills or medication? (please list them if so)

    What is your physician's name?

    Are you nervous about having dental treatment?

    Would you be interested in learning more about preventing dental disease?

    Have you or anyone in your family been advised of difficulties during anesthesia?

    Review & Submit

    Patients are requested to make payment at the time of your visit. Insured patients will be provided with insurance forms to file for reimbursement by their insurance company. Any other financial arrangements must be discussed with one of the staff prior to treatment.

    We prefer that a minor be accompanied by a parent for dental appointments. If this is not possible, the dentist will use his best judgment in treatment situations.

    By submitting this form, you are verifying that all information is correct.