The Houston Dental Group, Inc.
Giving you a lifetime of beautiful smiles
Dr. James Houston | 22901 Mill Creek Boulevard, Suite 140, Beachwood, Ohio 44122, 216.292.8499
Welcome!
We are glad you've chosen The Houston Dental Group as your preferred dentist. We'd like to make your first visit wtih us as easy as possible. Please take a few moments to complete our secure, online registration forms.
Name
Address
City
Home Phone
E-mail
State
Zip
Cell Phone
Date of birth [MM/DD/YEAR] / /
Gender [M / F]
Emergency Contact Information
Name
Home Phone
Cell Phone
Relationship
Name
Home Phone
Cell Phone
Relationship
Name
Home Phone
Cell Phone
Relationship
Are you a new or returning patient? New: Returning:
Preferred days for your appointment:
Preferred appointment times:
How did you hear about our practice?
How did you find our web site?
Please tell us what prompted this visit -
Insurance Information:
Carrier
Group Number
Patient Identification Number
Are you covered by more than one insurance policy? If so, please provide that information below:
Carrier
Group Number
Patient Identification Number
Please remember to bring your insurance information to your first visit
Copyright @ 2011
