create counter
Patient Forms

If you are a new patient, please fill out both pages of the registration form below BEFORE you arrive for your appointment. Filling them out before your scheduled appointment will allow us to attend to your dental needs more quickly. 

You may also fax a copy of the completed registration form along with a copy of your dental insurance card to our office at: 336-236-9555 or email them to us at:

Thank you and please call our office if you have any questions or need any assistance. 

New Patient Registration Forms





HIPAA Privacy Act (coming soon)

This web site uses files in Adobe Acrobat Portable Document Format (pdf) which require Adobe® Acrobat® Reader for viewing and printing. It is available to download free.