For your convenience, we have supplied our patient registration forms in two formats.

Simply click on the links below to choose between the Printable PDF version or the Online Patient Registration version. Please call our office if you have any questions.

• Patient Registration Form Package (PDF)
  
  
• Online Patient Registration

The Health Insurance Privacy and Portability Act (HIPAA) is a federal law designed to protect your personal health information.  Willits & Woltkamp Family and Cosmetic Dentistry is HIPAA compliant.  For your convenience, we have provided a printable version of our HIPAA Notice of Privacy Practices and Acknowledgement forms.  For new patients, please print, sign and bring the Acknowledgement form to your first visit.

New Patient Offer
Receive a FREE Consultation for Cosmetic Dentistry or Healthy Gums.

REWARDS PROGRAM
Refer a friend: you  and your friend will receive either a $25.00 Gift Card, or $50 off your next dental service.

Offers Expires:  Feb 04 2012

Simply complete the form below.  Thank you.