New patients get a $10 credit

To qualify, new patients must register at least TWO business days before your appointment

IMPORTANT: This form requires about 10-15 minutes to complete. You should complete the entire form in one sitting (you can’t temporarily save your answers).

Why do I need to fill out this form?

Our patients told us they were tired of writing their name, address, and medical history on 10 different paper forms, so we created an online form. You just enter your info once! 

Why do I need to complete the form two days in advance of my appointment?

To receive the $10 credit, we require the information at least two days prior to your appointment so we can thoroughly study your dental and medical history and plan for your treatment.

Can I earn the credit more than once?

Sorry, but the credit is only a one-time thing. We do want you to keep your information updated, however, so if you have changes to your health or personal information, please contact us.

Once I complete this form, I won't have to fill out paper forms later?

Correct! We’ll save your information in our secure dental database. If you change your address or need to update your medical information, we can collect that information and update your secure record.

Expect to spend 10-15 minutes completing this form! The more information we gather, the better we can meet your needs. IMPORTANT: Please do not hit the “Back” button in your browser (but feel free to use the “Next” and “Previous” buttons at the bottom of the form).


New Patient Form – $10 Credit!