Cosmetic Dentistry, Racine Dental Group of Racine, Wisconsin

On behalf of all of the Doctors and Staff of Racine Dental Group, S.C., we welcome you and are happy to assist you with your dental health care needs. As a new patient you will be required to complete a medical history form, a dental history form, and a patient information form. In an effort to make your first visit as comfortable and convenient as possible, we suggest that you complete a new patient packet before you arrive for your appointment.

The RDG New Patient forms are available in Adobe Acrobat .pdf format. In order to view and print these forms, you will need to have the Adobe Acrobat Reader installed on your computer. Click here to get the FREE Adobe Reader. You may download, open, print and complete these one page forms and bring them with you to your appointment, or mail them prior to your appointment.

For Existing Patients with a Dental Claim, Select and Download... ADA Dental Claims Form (1 page PDF document)

For Existing Patients, transferring to another Dentist who require a RELEASE OF RECORDS
Select and Download... Release of Records FORM (1 page PDF document)

1a) Select and Download All... Health History Information and Privacy Policies Forms
for "ADULT" (1 seven page PDF document)

1b) Select and Download All... Health History Information and Privacy Policies Forms
for "CHILD" (1 seven page PDF document)

2. INDIVIDUALLY Select and Download form...

Form 1: New Patient Registration Form (1 page)

Form 2a: Adult Medical History Form "age 13 and over" (1 page)

Form 2b: Child's Medical History Form "age 12 and under" (1 page)

Form 3: Dental History Form (1 page)

Form 4: Notice of Privacy Practices Form (1 page)

Form 5: Acknowledgement of Receipt of Notice of Privacy Practices Form (1 page)

Form 6: Accountability Confirmation Form (1 page)

Form 7: Wisconsin Consent Form (1 page)

3. REQUEST to be SENT BY MAIL.. click here!

You can also receive a packet by contacting our office at (262) 637-9371.

In addition, we also recommend that you request to have copies of your previous dental records and x-rays sent to our office at:

Racine Dental Group, S.C.
Registration Coordinator
1320 S. Greenbay Road
Racine WI 53406

(262) 619-7725

Thank you for choosing Racine Dental Group, S.C.
we are looking forward to serving you.