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New Patient Forms

Welcome! Please complete our New Patient Registration before your first visit. It takes about 10 minutes.


Have your dental insurance card handy. You can snap a photo of the front and back instead of typing in the details.


If you're registering more than one child, please fill out a separate form for each.


Your information is sent securely and is protected under our Notice of Privacy Practices. Questions? Call us at 201-612-1322.


This form has five short pages: patient and family, insurance, health history, communication preferences, and review and sign.

Who is filling out this form?
Parent or legal guardian
The patient (18 or older)
Someone else, such as a grandparent

If you are not the patient's parent or legal guardian, a parent or guardian will need to sign at the end of the form or at the first visit.

Patient date of birth
Month
Day
Year
Sex as listed with insurance
Male
Female
Other
What is the main concern? (check all that apply)
How did you hear about us?

Your contact information

We use this to confirm appointments and send reminders.

Your relationship to the patient
Home address
Who is responsible for the account?
The person filling out this form
The patient
Someone else
Add a second parent or guardian?
Yes
No
Legal custody
Both parents share custody
One parent has sole custody
Guardian or other arrangement

Family dentist

Your dentist keeps the patient's teeth healthy during orthodontic treatment, so we stay in touch with them.

Last dental visit (an approximate date is fine)
Month
Day
Year
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