Patient Registration

Please click the links below to fill out your Patient Registration, Health History, HIPAA Privacy Consent, General Consent, and Cancellation/Payment Policies Forms.  You can fill these out one of two ways:

1) Click each of the links below to fill out each of the forms, print the forms, then SIGN and bring them to your appointment.

2) Alternatively,  you can right-click to Download each of the the PDF files to Adobe Acrobat Reader (  Then fill out the forms with Adobe Acrobat Reader, SIGN, and click the “Submit” button at the bottom of each form in order to email the forms directly to us:

Registration-Form-Emrich Family Dentistry

ADA-Health-History-Form-Fillable Emrich Family Dentistry

Emrich Family Dentistry HIPAA

General Consent Emrich Family Dentistry

Cancellation-PAYMENT-POLICY-Emrich Family Dentistry