Pre-Registration

Thank you for choosing Harmony as your holistic dental care provider. To make your registration at the office go smoother and more efficiently, please fill out the form fields below. Please note, all new patients—except for children under age 18—must have an initial consultation with one of our doctors prior to scheduling a cleaning appointment.

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

How did you hear about us?

Insurance

I have dental insurance

I am uninsured

Member/Subscriber ID #

If insured, enter your Subscriber's First and Last Name

Subscriber's Date of Birth

YYYY

Relationship to Subscriber

Name of the Insurance Carrier

State in which the Insurance Carrier is Located

Insurance Carrier Phone Number

(###)

###

####

Dental concerns: