Submit Your Health History Form online to Dr. Smith's office

Save time at Dr. Smith's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form, click the "Submit Form" button at the bottom, and your information will be sent to our office with secure encryption. We will already have your information when you arrive for your first appointment. You will need to provide a signature at the office to verify that the information you submitted online is accurate.

Patient Information


Responsible Party Information


Medical History

Dental History

Dental Insurance Information

Insurance Company Address
Insurance Company Address

Emergency Information

Complete Address

By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.