Patient Registration

Please fill and submit the form below to request for the registration form.
We are happy to announce that we have two locations to serve you: Eureka and McKinleyville.
Please indicate where you would like to visit in the form below.

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.

CAPTCHA

IMPORTANT: Please alert the office if you have a medical condition that may be of concern prior to treatment (i.e., diabetes, high blood pressure, artificial heart valves and joints, rheumatic fever, etc) or if you are currently taking any medication (i.e., heart medications, aspirin, anticoagulant therapy, etc)

Completed Patient Registration forms MUST be received in our office prior to your visit so Dr Mehta can have the ample time to review all relevant health/dental history prior to be seen.

Please SUBMIT your registration forms as early as possible.

Patient Registration