Patient Registration Forms.
Welcome to Greene Endodontics! We thank you for choosing us in caring for your dental health.
Greene Endodontics is a dental practice dedicated exclusively to endodontic care. We are specialist members of the American Association of Endodontics. We look forward to being of service to you. If you are a new patient to our office, you will register in the office with an iPad. There’s no need to come any earlier than your scheduled time. We already block off enough time for registration.
Please do not fill out the forms below. We register our patients with iPads in the office. The forms below are only for legal guardians that cannot attend the appointment and have given written legal approval for another responsible adult to bring the patient to the appointment. Please call the office with any questions.
At your appointment, we will also need a list of medications you are presently taking. If you have dental insturance, bring the necessary forms. Children under the age of 18 (eighteen) must be accompanied by a parent or guardian.
The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.
Our office looks forward to provide you with the highest standard of care. If you have any questions, please don’t hesitate to contact us at: (765) 649-1277
We are open Monday-Thursday 7am-5pm. Friday. On Friday, a staff member is available by phone. The office is closed on Friday, we do not see patients. *Dr. Greene is available by phone for our patients’ emergency questions after hours.
Click the buttons below.
Please do not fill out the forms below ahead of time. We register our patients with iPads in the office. The forms below are only for legal guardians that cannot attend the appointment and have given written legal approval for another responsible adult to bring the patient to the appointment. Please call the office with any questions.
Pages 1-2: Please read through. These forms explain our privacy practices. The privacy of your health information is important to us.
Pages 3-6: Please download the forms and fill out the requested information. You can bring in your completed forms to your appointment or email at: info@endodoctorgreene.com
*The forms are in pdf format. If you cannot open the pdf documents, you can download the software for free. This software will enable you to view the forms. Click here, to download the pdf software (called adobe reader).
“Had a root canal and honestly Dr. Greene was fantastic it was painless and it was fast!!! He even called me later that evening to see how I was doing well after hours!!!” -Bobby C.