Dental Patient Registration Forms

Patient Registration

You may preregister with our office by filling out our secure online Patient Registration forms. After you have completed the form, please make sure to press the Complete and Send button at the bottom to automatically send us your information. After you submit your registration, you will be able to securely upload and send an image of your insurance card.

Patient Registration

The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.


We will also have patients complete an online questionnaire prior to coming to our office. Please call our office if you have any questions: Forsyth IL Periodontal Office Phone Number 217-876-0547 (Forsyth) or Springfield IL Periodontal Office Phone Number 217-787-0422 (Springfield).


Pre-Appointment Screening

In light of the Coronavirus outbreak, all patients will need to complete this questionnaire to help assure your safety and the safety of those around you before being seen at the office. Thank you in advance for completing it.

COVID-19 Patient Screening form

Please note:

  • If you answer YES to any of these questions, please call the Forsyth office: Forsyth IL Periodontal Office Phone Number 217-876-0547.
  • If all your answers are NO, we will see you at your regularly scheduled appointment time, where these questions may be asked again and your temperature was taken with a no-touch thermometer.

Again, thank you for your cooperation.