Patient Registration

You may preregister with our office by printing our Patient Registration form (available below). This form is two pages long; please be sure to fill out the Medical History portion as completely as possible. After you have completed your Patient Registration form, please make sure to bring it with you at the time of your appointment.

Patient Registration Form

You may also fill out the following forms as necessary:

COVID-19 Emergency Dental Treatment Notice

COVID-19 Patient Disclosures

Financial Policy

Privacy Practices Acknowledgement of Receipt

Technical Note

The above forms are in PDF format. If you are unable to open and print out a form, you may download and install Adobe Acrobat Reader for free to help you. We are also available in the office, if you have questions: Endodontic Specialty Care Phone Number 773-792-2369.