Hilton Head Dental PA

Experience the Difference

Thank you for Selecting Our Dental Team

To help us meet all your healthcare needs, please fill out this form completely in ink.
If you have any questions or need assistance, please ask us and we will be happy to help.

Patient Information
(confidential)




Student Information
(Skip this if you are not a student)


Employment
(If unemployed, enter your spouse or parent's employer instead)


Emergency Contact


Responsible Person
(If same as patient, please still enter information)


Insurance Information
(skip if you have no insurance)

By clicking Next you certify that all information is accurate and completed by the patient or responsible party.