Free Dental Clinic Registration Form Template
Dental Clinic Registration Form
Please fill out this form completely to register for your dental treatment and help us provide personalized care.
Personal Information
Name
Date of Birth
Gender
-
Male
-
Female
-
Phone number
Address
Emergency Contact
Name
Phone number
Relationship
Medical History
Do you have any allergies?
If yes, please list:
Are you currently on any medications?
If yes, please list:
Have you had any major surgeries or treatments?
If yes, please provide details:
Dental History
Have you had previous dental treatments?
If yes, please describe:
Do you have any current dental concerns?
If yes, please describe:
Payment Method
-
Cash
-
Credit/Debit Card
-
Insurance
-
Digital Payment (e.g., PayPal, Venmo)
Consent and Acknowledgment
-
I consent to receive dental treatment and understand the privacy practices of the clinic.
Name:
Date:
Thank you for completing the registration form.
We look forward to serving your dental care needs!
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