New Private Patient Registration Form

Cap City Dental welcomes all new patients. If you are not registered with a dentist but need treatment, please complete the form below. We will then contact you with the next steps.

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Name *

Telephone *

Email *

Date of Birth *

there you'd Payment

Gender

• Male
• Female
• Other

Medical Questions

• Nervous patient?
• Taking any medication?
• Pregnant?
• Allergies?
• Asthma, Bronchitis, Covid?
• Bone/Joint condition?
• HIV, Hepatitis, Epilepsy
• Diabetes, High Blood pressure
• Smoke?

Choice of Payment

• Pay as you go
• Dental Insurance
• Dental Plan

Is there anything else you'd like to tell us?

Submit