MCDC Online Registration Form
If you feel you have a dental emergency, please contact our Patient Experience Center directly at 1-877-313-6232 Monday through Friday between the hours of 8 am - 5 pm., 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. Please make sure that you fill out the form completely to enable us to process your registration.
How did you hear about My Community Dental Centers? *
What is your primary language? *
Your answer
Parent or Legal Guardian Full Name and Date of Birth: *
If you are registering your child OR an adult with a guardian, we require that you include the parent or legal guardian name to process your registration. Please type NA if this does not apply to you
Your answer
Patient's First Name: *
Your answer
Patient's Last Name: *
Your answer
Patient Date of Birth: *
MM
/
DD
/
YYYY
Gender: *
Marital Status: *
Street Address: *
Your answer
City, State and Zip Code: *
We require your full address in order to process your registration. Please make sure to add this information!
Your answer
Main Phone Number: *
Your answer
Second Phone Number: *
Your answer
Emergency Contact Name and Phone Number: *
Your answer
How would you like us to contact you for appointment confirmations? *
Email Address:
Your answer
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
Your answer
Social Security Number *
Needed for Insurance Verification
Your answer
Name of Employer *
This is required if you have dental insurance through your employer. If this does not apply to you please type NA
Your answer
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
Your answer
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
Your answer
Dental Insurance - Customer Service Phone Number for Verification: *
Type NA if this does not apply to you
Your answer
Do you have a second dental insurance? *
Second Dental Insurance Company Name: *
Type NA if this does not apply to you
Your answer
Second Insurance Member ID and Group Number: *
Type NA if this does not apply to you
Your answer
Second Insurance - Customer Service Phone Number (for verification): *
Type NA if this does not apply to you
Your answer
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