Your Privacy: Information transmitted from this page is encrypted and secure. Your data will never be used by anyone other than your healthcare provider.
Patient Sign-in

Patient Registration Form-Child

Eau Claire Family Dental

1018 Regis Court,
Eau Claire, WI 54701
(715) 832-8063

Patient Information( * mandatory to fill )
  •  Text Message
  •  Email
  •  Cell Phone
  •  Home Phone
PATIENT INFORMATION( * mandatory to fill )
Responsible Party's Information( * mandatory to fill )
Insurance Information( * mandatory to fill )
  •  Yes
  •  No
ADDITIONAL INSURANCE( * mandatory to fill )
AUTHORIZATION( * mandatory to fill )


I certify that I, and/or dependent(s) have insurance coverage and assign directly to this dental office all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

(Please click below to draw/upload sign)
(Your IP Address : IP: )
Copyright ©2020
Your browser doesn't support signing