On-Line Registration forms
You can register as a new patient on this form. We take your privacy seriously so all data is encrypted and highly secure.
Use the Tab button to move between sections. Every section will need to be completed and signed before the application can be processed. Click the Submit button at the end of the process to complete your application.
You can also download and complete the form here. You can drop the form off with the receptionist before your first appointment. You can click here if you need to download Adobe Acrobat.
We will be in touch with you as soon as possible.
Please feel free to call us at (602) 841-0002 if you have any questions.
Print PDF New Patient Registration Click Here – Front Side of Form
Click Here – Back Side of Form
HIPPA Consent Form
You can also print our HIPPA consent form and bring this in with your new patient form.
Click Here – HIPPA Form
CareCredit Assistance
You may qualify for assistance from CareCredit if your insurance doesn’t cover your treatment. You can use your CareCredit card to pay for both general and cosmetic dental services.
CareCredit members will receive a card that allows them to pay for their dental care without upfront fees or pre-payment penalties. You won’t need to pay any interest if you make the minimum monthly payments and pay the entire bill by the end of the payment period.
You can contact us at (602) 841-0002 if you have any questions. You can also apply for CareCredit at their website.
