New Patient Registration Form
If you feel that you have a dental emergency, please contact our Patient Services Department directly at 877.313.6232 between 8 am - 5 pm Monday through Friday, excluding major holidays. Your online registration will be processed within one business day of submission. One of our representatives will call you to schedule your appointment once your registration is processed.
How did you hear about My Community Dental Centers? *
What is the Primary Language you speak, read, & write? *
Your answer
Patient's First Name: *
Your answer
Patient's Last Name: *
Your answer
Full Name of Legal Guardian: (If applicable)
We require the name of a child's legal guardian to complete registration.
Your answer
Patient Date of Birth *
MM
/
DD
/
YYYY
Gender *
Marital Status: *
Address: *
Please enter your FULL address, including PO Box/street, city, state, and zip code! We require a full address to properly process registrations.
Your answer
Primary Phone Number: *
Your answer
Secondary Phone Number *
In the event we are unable to reach you at your primary number.
Your answer
Primary Email Address:
Your answer
Which dental center do you wish to visit? *
If you are unsure, please visit our website at: http://www.mydental.org/office-locations to select your closest location.
Are there any other immediate family members registered as patients? *
Anyone who lives in the same household as you currently do.
Who is considered the Head of Household? *
Your answer
What is your Primary Insurance? *
Employment Status *
Primary Insurance -Employer
Your answer
Primary Insurance -Employer Address:
Your answer
Primary Insurance -Customer Service Phone Number:
Your answer
Medicaid Insurance Number: *
enter all digits - if this does not apply - type NA
Your answer
Social Security Number - Used to assist with Registration process
If you do not want to share - please bring to your first appointment
Your answer
Do you have a secondary Insurance *
What is your Secondary Insurance? *
Type: NONE if you do not have one.
Your answer
Secondary Insurance - Employer
If does not apply - type NA
Your answer
Secondary Insurance - Employer Address
If does not apply - type NA
Your answer
Secondary Insurance - Customer Service Phone Number
If does not apply - type NA
Your answer
If you are uninsured, you may qualify to participate in our reduced fee program.
Our staff will contact you to provide you with information to submit your payment.
Your answer
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