Forms
In this section, you can choose which intake form to fill out. It is a TWO page form, in either English or Spanish so please remember to print both pages. First, click on the links of your choice. When the form(s) appear, RIGHT-CLICK on each of the pages and select “PRINT”.
Of course, you also have the option to fill out the form(s) during your initial visit!
Online Patient Registration
You may preregister with our office by filling out our secure online Patient Registration Form. 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.
Note to Patient: Upon filling out your first name, last name, email and at least one phone number field (a valid home or cell phone) a button will appear in the upper right corner titled “Save and Exit” . This button allows you to save and exit your form to complete at a later date. The system will send a registration email to the email provided on the form, so that you may setup a login to go back and finalize your registration form online.
You Deserve to Smile Again!
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I understand the information disclosed in this form may be subject to re-disclosure and may no longer be protected by HIPAA privacy regulations and the HITECH Act.
