RCT starting at $900 Same Day Emergency Treatment

Patient Registration

Step 1 of 4 - Patient Registration

PLEASE COMPLETE THE FOLLOWING CONFIDENTIAL INFORMATION

IF THIS APPOINTMENT IS FOR YOU START HERE:

Name

First Name: Last Name:

MI:

Date of Birth:

Preferred to be called by:

Street Address:

Apt./Unit #:

City:

State:

Zip Code:

Home Phone:

Fax:

Mobile No:

Email

Gender:

Male

Female

Marital Status:

Married

Single

Divorces

Widowed

Social Security No:

IF THIS APPOINTMENT IS FOR YOUR CHILD START HERE:

Name

First Name: Last Name:

MI:

Date of Birth:

Preferred to be called by:

Street Address:

Apt./Unit #:

City:

State:

Zip Code:

Home Phone:

Email

Gender:

Male

Female

Mobile No:

Grade:

Social Security No:

IF YOUR CHILD'S LAST NAME AND/OR ADDRESS ARE NOT THE SAME AS YOURS, FILL IN THE TOP BOX ALSO

Our Office

831 Harris St. Eureka, CA 95503

Phone: (707) 375-9698

Fax: (707) 443-1467

Email: info@drmehtadentist.com

Hours

Monday: 8 AM - 5 PM

Tuesday: 8 AM - 5 PM

Wednesday: 8 AM - 5 PM

Thursday: 8 AM - 5 PM

Friday: 8 AM - 5 PM

Saturday: 8 AM - 5 PM

Sunday: Closed

Terms & Conditions

Privacy Policy

Please enter your name, email and phone number:

Name(Required)

First Last

Email(Required)

Phone(Required)

Which of our clinics will you be visiting?(Required)

We serve both the Eureka and at the McKinleyville locations. Please pick the location that you would like to visit from the drop down.

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