Skip to main content

Patient Forms

If you’re a new patient to Scripps Center for Dental Care, we want to help make your first visit as comfortable and convenient as possible. Our patient registration and health history forms are available online for you to either print and bring with you, or fill out online. You also have access to our HIPAA Notice of Privacy Practices, and we take the security of your personal data very seriously. If you would like to know more about any information you find here, or any treatment we suggest, we welcome your questions.

Option 1: PDF Download and Print

If you would like to complete paper copies of the forms, please use this option to download the PDF’s and print at home. Bring completed forms with you to your appointment.

New Patient Registration

Dental History Form

Option 2: Complete Online

Use this option if you would like to complete your forms online. After you are done, click the “Submit Form” button, to certify that the information provided is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

(click each title to expand)

New Patient Registration

Responsible Party ( if someone other than the patient )

Patient Information

Section 2

Section 2

Primary Insurance Information

Secondary Insurance Information

Health History

Dental History

At Home Oral Hygiene Care