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New Patient Registration

Please submit this form prior to calling to schedule a new patient. Thank you!

Patient Information:

If additional siblings please indicate at the bottom of the form. If you have already completed the rest of this form for a sibling that we currently treat, please tell us who we can transfer this information from and you may skip completing the remaining sections of this page.

Dental History:

Parent/ Guardian 1 Information:

Parent/ Guardian 2 Information:

Dental Insurance:

Please press submit after completing this form. Once our office receives the form we will call you to schedule your appointment. If you prefer you may call us directly at 585-244-1177.


Once your patient account is made we will email you a link to your Patient Portal where you will complete the Medical History, Dental history, and Financial Policy forms. 

Thanks for submitting!

Our office will contact you to schedule an appointment or you can call us at 585-244-1177.

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