New Patient Registration

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Online Patient Registration

You may preregister with our office by filling out our secure online Patient Registration Form. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information. On your first visit to our periodontics and implant practice office, we will have your completed form available for your signature. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

Technical Note:

PC Users
Our online form uses the latest version of Adobe Acrobat Reader to conveniently submit the form from home or work. Please download the free plug-in from Adobe’s web site if it is not already installed on your system. It is important that you have at least version 9 of the plug-in to successfully use our online form.

Mac Users
You must open and submit the form in a Safari Browser with the latest Mac operating system. It is also important to have the latest version of Adobe Acrobat Reader on your computer in order to submit your form to our office correctly, please download the free plug-in from Adobe’s web site.

Have Additional Questions? Call Now!
Fayetteville: (479) 282-2620  | Rogers: (479) 282-2628  | Fort Smith: (479) 282-2629  | Harrison: (855) 401-8444

Ready to Schedule Your Appointment? Click Here!
    

Fayetteville Office

2001 Green Acres Rd
Fayetteville, AR 72703
New Patients: (479) 282-2620
Current Patients: (479) 521-6400

Rogers Office

300 South Metro Pkwy
Rogers, AR 72758
New Patients: 479-282-2628
Current Patients: 479-636-8800

Fort Smith Office

3800 Rogers Ave #3
Fort Smith, AR 72903
New Patients: 479-282-2629
Current Patients: 479-785-4848

Harrison Office

1405 McCoy Dr
Harrison, AR 72601
New Patients: 855-401-8444
Current Patients: 866-521-6400

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