Registration Form & Medical History

Registration Form & Medical History

Island Perio – Patient RegistrationPlease assist us at the time of your initial visit to the office by providing the following information:

  • Your referral slip and x-rays from your referring dentist (these may have been sent directly to our office)
  • A completed Patient Registation and Medical History Form [PDF]
  • A list of medications you are currently taking
  • Dental insurance information

Please note: All patients under 18 must be accompanied by a parent or guardian at the initial examination appointment