Formularios del Paciente

Full-Service Dental Care

Por favor complete los siguientes 4 formularios para registrarse como paciente. Puede usar los botones Anterior / Siguiente para moverse entre las secciones, y el botón Guardar y Continuar Más Tarde si necesita pausar.

Please complete the 4 forms below to register as a patient. Use the Previous / Next buttons to move between sections, and Save and Continue Later if you need to pause.

1Registro
2Pediátrico
3Odontológico
4Médico

Registro de Pacientes

Información del Paciente

MM slash DD slash YYYY
¿Usted o algún miembro de su familia ha sido visto en University Dental Associates antes?
Título
Title (Dr./Mr./Mrs./Miss/Ms.)
Nombre(Required)
MM slash DD slash YYYY
Sexo
Sex
SS#
Dirección de Residencia

Información del Cónyuge

MM slash DD slash YYYY

Contactos

Contacts

Información de Pago

MM slash DD slash YYYY
Dirección del Responsable de Pago
Tengo beneficios odontológicos para ayudar a cubrir el costo del tratamiento
Pienso pagar el tratamiento no cubierto con:

Información de Beneficios Odontológicos

Dirección de la Empresa de Beneficios
Group Number

Por favor proporcione su tarjeta de beneficios odontológicos a UDA para fotocopiar.
Please provide your dental benefits card to UDA for photocopy.

Entiendo que la información ingresada en esta sección de registro es necesaria para brindarme atención odontológica de manera segura y eficiente. He contestado todas las preguntas a mi leal saber y entender. Notificaré al consultorio sobre cualquier cambio en mi información personal, contacto, pago o beneficios.

Consentimiento (Registro)(Required)

Our Dental Offices Near You

University Dental Associates High Point

2021 Eastchester Drive Suite 101 High Point NC 27265 336-885-6511 (p)
336-885-6577 (f)
University Dental Associates High Point

University Dental Associates Greensboro

3712 Lawndale Drive Suite D Greensboro NC 27455 336-419-1099 (p)
336-419-1103 (f)
University Dental Associates Greensboro

University Dental Associates Kernersville

1030 S Main St Suite B Kernersville NC 27284 336-497-3740 (p)
336-497-3749 (f)
University Dental Associates Kernersville

University Dental Associates Hawthorne

1615 S Hawthorne Rd Winston Salem NC 27103 336-768-3454 (p)
336-768-4986 (f)
University Dental Associates Hawthorne

University Dental Associates Cloverdale

2287 Cloverdale Ave NW Winston-Salem NC 27103 336-837-2680 (p)
336-837-2681 (f)
University Dental Associates Cloverdale

University Dental Associates Clemmons

6201 Town Center Dr Suite 130 Clemmons NC 27012 336-778-9199 (p)
336-778-9266 (f)
University Dental Associates Clemmons

University Dental Associates Pediatrics Clemmons/Lewisville

2311 Lewisville Clemmons Rd Suite 301 Clemmons NC 27012 336-631-4770 (p)
336-631-4558 (f)
University Dental Associates Pediatrics Clemmons/Lewisville

University Dental Associates Village Link

2020 Village Link Dr Winston-Salem NC 27106 336-923-4262 (p)
336-923-4281 (f)
University Dental Associates Village Link

University Dental Associates Weston

9944 Chapel Hill Road Morrisville NC 27560 919-238-7649 (p)
919-238-7654 (f)
University Dental Associates Weston

University Dental Associates Mecklenburg Mallard Creek

10320 Mallard Creek Rd Suite 160 Charlotte NC 28262 704-494-7394 (p)
704-494-7399 (f)
University Dental Associates Mecklenburg Mallard Creek

University Dental Associates Benfield

10018 Benfield Road Suite 204 Charlotte NC 28269 704-228-0311 (p)
704-228-0310 (f)
University Dental Associates Benfield

University Dental Associates Charlotte University - UDA1

8401 University Executive Park Dr Suite 110 Charlotte NC 28262 704-547-1970 (p)
704-547-1926 (f)
University Dental Associates Charlotte University - UDA1

University Dental Associates Charlotte University II - UDA2

8305 University Executive Park Dr Suite 300 Charlotte NC 28262 704-547-1279 (p)
704-549-8390 (f)
University Dental Associates Charlotte University II - UDA2

University Dental Associates Interchange

801 Jones Franklin Road Suite 150 Raleigh NC 27606 919-852-0403 (p)
919-852-0562 (f)
University Dental Associates Interchange

University Dental Associates Northlake

9304 Northlake Drive Suite A Charlotte NC 28216 980-221-8430 (p)
980-221-8435 (f)
University Dental Associates Northlake

University Dental Associates Campus North

807 Spring Forest Rd Suite 600 Raleigh NC 27609 919-954-7177 (p)
919-954-0517 (f)
University Dental Associates Campus North

University Dental Associates Waxhaw

9815 Suzanne Court Waxhaw NC 28173 704-845-1425 (p)
704-845-1580 (f)
University Dental Associates Waxhaw

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What Our Patients Say

  • What a team! From the reception staff to the hygienists to the doctors, everyone is warm welcoming and outstanding customer service. Building is clean and organized. They don't shame you but instead educate you on dental health. All in all, the best dentist office I have ever gone to and I won't be changing any time soon!

    Elizabeth K.

    NY

  • I'll make it short and sweet. The staff has been absolutely phenomenal, they're always quick to get me in, and I've never had a better experience anywhere else. They have two concerns, my comfort (both physical and mental) and my teeth, and it's in that order. Don't go anywhere else, if you do you're missing out

    Joshua K.

    NY

  • Love this office! Very friendly, professional Staff. My kids love the waiting area. Excellent care!

    Holly N.

    NY

  • Out of all the dentists that take my insurance, they were the only who would get me in within 24 hours for an emergency. All the rest said 3 weeks to month. I have dental anxiety but not the traditional fear of pain and needles kind. The kind that stems from over 30 years of having dental problems and no dentist ever listening to me and taking me seriously. So, I've given up. But, already in just one visit, WNY Dental has been different. I don't expect a miracle, and even if in the end, It's ....

    Amy L.

    NY

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