To speed up processing when you visit us, please fill out this online patient registration form and click "Submit". Your information will go directly to our office staff.  

Patient Information
Date *
Date
Type "Patient Registration"
Name *
Name
Address *
Address
Home Phone
Home Phone
Cell Phone
Cell Phone
Work Phone
Work Phone
Date of Birth
Date of Birth
Please indicate who referred you to us.
MEDICAL HISTORY
Are you currently under a physician's care?
Example of medical problems requiring pre-medication (Mitrol Val Prolapse, Artificial Heart Valve, Hip/Knee Replacement)
Please check any illnesses you have had or suspected:
Breastfeeding?
Are you taking oral contraceptives?
Do you have any problems with your Temporal Mendibular Joint (TMJ, TMD)?
PAYMENT POLICY
Credit Card Authorization and Verification Form. All Charges are due on the date of service. We accept Cash, Check, Major credit cards and CareCredit. We do not accept MNSure, Ucare, or Medicare.
How will you be paying today?
I fully understand and will comply with this policy. *
DENTAL INSURANCE
If you have and would like to use dental inurance, we are happy to accommodate you, but we must have a secondary payment in place to cover any unpaid charges. CareCredit, or a major credit card would be acceptable. “Credit cards will be authorized (not charged) for the total amount due on the date of service and any remaining balance will be charged, after the insurance payment is received.
I authorize Great Lakes Endodontics to charge my credit card for applicable charges.
Primary Dental Insurance Information
Employee's Name
Employee's Name
Employee's Date-of-Birth
Employee's Date-of-Birth
Employee's Address
Employee's Address