New Patient Registration

First Name*

Last Name*

Date of Birth*

Phone Number*

Email Address

Street Address

Preferred Language

Emergency Contact Name

Emergency Contact Phone

When was your last dental visit?*

• Within the last 6 months
• 6 months to 1 year ago
• More than 1 year ago
• Never been to a dentist

Main reason for this visit*

Describe any current dental concerns

Previous Dentist Name (if any)

Select all that apply

• Heart disease
• High blood pressure
• Diabetes
• Asthma
• Bleeding disorder
• Hepatitis
• HIV/AIDS
• Cancer (current or past)
• Thyroid disorder
• Joint replacement
• Other (describe below)

Please describe other conditions

List your current medications

List your allergies

How will you be paying?*

• Medi-Cal (Denti-Cal)
• Private dental insurance
• Self-pay (no insurance)
• Other / not sure

My insurance card

• I don't have my insurance card right now — I'll provide details before my appointment

Insurance Company

Member ID

Policy / Subscriber Number

Group Number

Plan Name

Effective Date

Expiration Date

Member services phone

RX BIN

RX PCN

Other card details (everything our scanner could read)

Auto-filled from your scanned card. You can edit or add anything you see on the card that's missing above.

Medi-Cal Beneficiary ID (BIC Number)*

Electronic Signature*

Signature