MCDC Online Registration Form
Your online registration will be processed within one business day of submission. One of our representatives will contact you to schedule your initial appointment once your registration has been processed. Please make sure that you fill out the form completely. If you feel you have a dental emergency, please contact our Patient Experience Center directly by calling 1-877-313-6232 Monday through Friday between the hours of 8 am - 5 pm., excluding major holidays.
How did you hear about My Community Dental Centers? *
Do you have a spouse or child under the age of 18 who is an MCDC patient? If yes, please list any names and dates of birth?
What is your primary language? *
Parent or Legal Guardian - Full Name : *
If you are registering your child OR an adult with a guardian, we require that you include the parent or legal guardian name, date of birth, and relationship (parent or legal guardian) to process your registration. Please type NA if this does not apply to you.” (Note that this question does not apply to a power of attorney holder for the patient.)
Patient's First Name: *
Patient's Last Name: *
Patient Date of Birth: *
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Gender: *
Marital Status: *
Mailing Street Address: *
City & State: *
We require your full address in order to process your registration. Please make sure to add this information!
What is your Zip Code? *
Cell Phone Number: *
Home Phone Number: *
Emergency Contact Name, Phone Number and Relationship to Patient: *
How would you like us to contact you for appointment confirmations? *
Email Address:
Are you a Veteran?
Which dental center do you wish to visit? *
If you are unsure please visit our website at: https://www.mydental.org/office-locations/ to find the closest location to you.
What type of Dental Insurance do you have? *
Medicaid ID Number: *
Type NA if this does not apply
Social Security Number *
Needed for Insurance Verification
Name of Employer *
This is required if you have dental insurance through your employer. If this does not apply to you please type NA
If you have dental insurance through your employer OR have a dental insurance policy that you pay for individually, please list the dental insurance company name: *
Please type NA if this does not apply to you
What is your Dental Insurance ID and Group number? *
This information is listed on the front of your dental insurance card - Please type NA if this does not apply to you
Dental Insurance - Customer Service Phone Number for Verification: *
Type NA if this does not apply to you
Do you have a second dental insurance? *
Second Dental Insurance Company Name: *
Type NA if this does not apply to you
Second Insurance Member ID and Group Number: *
Type NA if this does not apply to you
Second Insurance - Customer Service Phone Number (for verification): *
Type NA if this does not apply to you
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