Patient Registration

Please complete all information about the patient to the best of your ability. If you are a parent filling out the form for your child please enter your child’s information in the patient info and your information on the responsible party section of the form.

This form has 5 sections and can take 10-20 minutes to complete. Nothing on this form is required so you are free to fill it out to the best of your ability or comfort level. You can submit the form on page 6, after the dental health history.

If this is a dental emergency, please call our office number 920-465-9887 and leave a message.