Patient Registration

Status *
Sex *
Are you a student? *
Full Time: *
Full time college students using parent's insurance plan must provide proof of full-time student status.
Name of parent or legal guardian accompanying minor:
For children under 18 years of age, the legal guardian or parent accompanying the child to this appointment is deemed the responsible party for the payment on this account.

Emergency contact

Name of a friend or relative not living with:

Referred by


I authorize the doctors or staff to discuss my care and/or treatment with my primary emergency contact listed above. *
Methods of Payment Accepted: Cash, Debit, Credit, Money Order, Care Credit. 
I will be paying today by: *
Signature (Parent or guardian, if patient is a minor) *
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