Patient Registration Forms

Convenient, Online Registration

Here at Silberg Dental, we want your experience to be as convenient as possible. For that reason, we have our patient registration forms available online. These forms can be filled out and transmitted electronically, or printed, filled out, and returned to our office. Here are a few key pieces of information you will need to have handy to complete this document:

  • Contact Information: In addition to your name and address, we ask for your social security number, your birthdate, and your phone number. Although it might seem like a lot to give to a dental office, this information can help us to match your insurance to your services.
  • Who Referred You: If you have a complex dental issue that has plagued you for years, we might need to contact your prior dental professionals. Please include information regarding who referred you and why.
  • Insurance Information: Our patient registration form also asks for all of your insurance information—primary and secondary. We need the member ID numbers, in addition to the insurance carrier’s name, address, and phone number.
  • Account Responsibility: If you won’t be the one footing your own dental bill, we need to know who will be paying for your services. This section is especially important for anyone who is covered under a family member’s dental insurance policy.  

Register Online Now

Security Is Our Top Priority

Here at Silberg Dental, our patient’s privacy is our top priority. We use an encrypted, secure connection to collect and store your patient forms. However, if you have concerns about your information privacy, feel free to print off the form and return it to our office prior to your visit. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

Thank You For Helping Us!

Thank you so much for filling out your patient registration forms ahead of time. In addition to speeding up patient registration, it also reduces lags in the waiting room, which can disrupt our schedule. Also, we have noticed that when patients have time to fill out forms at their own convenience, it reduces data entry errors such as misspellings and incorrect phone numbers. We want to bill your insurance correctly, so that you can avoid billing mistakes and frustrating hassles. 

If you have any questions or concerns as you fill out the new patient forms, please feel free to give our office a call.  Our office manager will be happy to help. On your first visit to our office, we will have your completed form available for your signature.

After your forms are complete, you will be in our system and we will not ask for additional information unless something changes. Please let us know if your address, phone number, contact information, or insurance plan changes at any time. To make changes, all you need to do is fill out a new version of our secure online form. However, please make our office manager aware of the change so that they can look for updated information.  

We work closely as a team with your referring dentist, but a referral by a dentist is not required for a visit to our office. We welcome referrals from patients and friends of the practice.

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