Julian Center

5012 Dorsey Hall Drive, Suite #205 Ellicott City, Maryland 21042

(410) 964-3118 Call Today!

Online Patient Registration Form

Step 1 of 6 - Personal Information

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  • A firm foundation is needed upon which to base recommendations for your health. Therefore, we ask that you complete the entire Registration and Health History form. The information you provide will ensure safe treatment, aid us in diagnosis and treatment planning as well as help identify any precautionary measures we may need to take to protect your health. The information you provide is STRICTLY CONFIDENTIAL.

  • Date Format: MM slash DD slash YYYY
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  • Date Format: MM slash DD slash YYYY

  • Payment in full is expected at time of service, unless other arrangements have been made. For your convenience we accept cash, personal checks & credit cards. A deposit will be required to hold the time and date of your appointment. This will be credited toward your treatment. This deposit is non-refundable; if you need to reschedule your appointment we require a minimum of 48 business hours notice.
    Your time is important to us. We do not run our office like a clinic with ten or more patients stacked up in the waiting room. The time we schedule for you is yours alone to receive the individual attention and quality care you deserve. So if you cancel or fail to show for your appointment, two people are hurt:
    1. You, because you’re not getting the care you need,
    2. Another patient waiting for an appointment who is being prevented from receiving treatment, So, please be on time and keep your appointments.

    There will be a minimum charge of $150 for canceling an appointment with less than 48 business hours notice.

    In case of emergency please contact (closest relative or friend):

  • I understand that I am responsible for all costs of my treatment. *I authorize the release of any information relating to this claim. I have read and agree to the terms stated above and that all information is true.

2019 Julian Center for Comprehensive Dentistry

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