770-303-2655 info@grinvilledentalclinic.com

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New Client Registration at GrinVille Dental Clinic

Welcome to GrinVille Dental Clinic! We are delighted to have you as a new patient.
Please fill out the form below to help us tailor our care to your needs. Your information will be kept confidential.

Get Started

New Patient Form

To provide the best care, please complete the form below with your personal, medical, and dental history.

Step 1 of 5

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Personal Information

Name(Required)

First Last

Date of Birth

Address

Street Address Address Line 2 City State ZIP Code

Phone Number

Email Address(Required)

Enter Email Confirm Email

Emergency Contact

Name

First Last

Relationship

Phone Number

Medical History

Allergies

Yes

If yes, please list

Current Medications

Chronic Illnesses or Conditions

Yes

If yes, please specify

Surgeries

Yes

If yes, please list

History of Heart Disease, Diabetes, or Other Significant Health Issues

Yes

If yes, please explain.

Dental History

Reason for Visit

Current Dental Pain

Yes

If yes, please describe

Frequency of Dental Visits

Dental Concerns or Issues

Yes

If yes, please describe.

Previous Dentist's Name and Contact Information

Dental Practice Name

Doctor's Name

First Last

Phone Number

Email Address

Insurance Information

Dental Insurance

Yes

Insurance Provider

Policy Number

Group Number

Subscriber’s Name

First Last

Relationship to Subscriber

Preferences and Additional Information

Preferred Appointment Times

Morning

Afternoon

Evening

How Did You Hear About Us?

Referral

Internet Search

Social Media

Other

Please Specify Other

Additional Information or Special Requests

Consent

By submitting this form, you agree to our privacy policy and consent to our use of your information for your dental care. If you have any questions, please contact our office.

I agree to the privacy policy.

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Phone

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