Patient Registration Step 1 of 425%Today's Date PATIENT INFORMATION Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone NumberBest # to reach youOther PhoneIf there's another # to reach youSocial Security #Your Date of Birth Email Referred ByPlease Select One*I am the Responsible PartyI am NOT the Responsible Party RESPONSIBLE PARTY- if other than the patient Relation to PatientName First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneSocial Security #Date of Birth Email Please Check Your Dental Concerns Select all that apply.Teeth Broken or Chipped Crooked Decay Discolored Food Trapping Areas Grinding/Clenching Loose or Missing Filling Loose Tooth/Teeth Missing Tooth/Teeth Mouth Sores Hot/Cold Sensitive Sensitive to SweetsGums Bleeding Pimple or Bump Sore/SensitiveOtherOn a scale of 1-10, with 10 being the highestHow happy are you with your smile?12345678910How concerned are you with your overall dental health?12345678910 Insurance Information Insured's EmployerInsurance CompanyGroup #Insurance Company Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Past Dental History Dental Visit FrequencyMonthlyYearlyAs NeededLast Dental VisitDo you have Tooth Replacement such as Dentures, Bridges, or Implants?YesNo{{{error}}}