585 Dentist

Two Great Locations!

Covering Rochester “coast to coast” from the original Greece location to the newest location near Eastview Mall.

New Patient Registration

Speed up your first visit by filling out this registration form online. It covers the same information as our paper patient registration form. Prefer a printable PDF? Download the new patient form.

Patient

Patient Is

Patient Information

Sex
Marital Status

Employment, Student & Emergency

Employment Status
Student Status

Primary Insurance Information

Employer address

Insurance company address

Secondary Insurance Information (optional)

X-ray or document (optional)

Optional. Images or PDF (.jpg, .png, .tif, .pdf). Multiple files OK.

Required: patient first name, last name, birth date, and either a phone number or email.