MARK WHITFIELD, DDS, FAGD | UPTOWN DALLAS DENTIST 214.979.3278
March 11 2010 | 3:07 AM
Registration
DENTAL REGISTRATION AND HEALTH HISTORY
You may pre-register with our office by filling out our secure online Patient Registration and Health History Form. After you have completed the form, please make sure to press the Submit button at the bottom of the third page 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. Your personal data will be submitted using 128-bit encryption. If you don’t want to pre-register online, please contact us and we can send you the required forms for you to complete prior to your first appointment.
DATE
Patients Name
How do you prefer to be addressed?
Mailing Address
City
State
Zip
Sex
M
F
Birth date
Single
Married
Widow
Separated
Divorced
SS#
Home Phone Number
Work Phone Number
Email Address
Occupation
Employer
Employer's Address
City
State
If Student , name of School/College
City
State
PT
Full
Whom may we thank for referring you to our office:
If the person responsible for this patients account is different from the patient or if this patient is a minor, the responsible party must fill out the section below. Otherwise, please skip to the section titled "
Insurance Infomation
"
Name of responsible party
Relationship to Patient
Mailing Address
City
State
Zip
Sex
M
F
Birth date
Single
Married
Widow
Separated
Divorced
SS#
Home Phone Number
Work Phone Number
Occupation
Employee
Employer's Address
City
State