Advanced Family Dentistry Contact Information (Fishers)

Contact Information

Please enter all information to the best of your ability to help us get you registered prior to your arrival.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Phone Number*

CellHomeOther
Email*
example@example.com
Social Security Number*
Date of Birth*

MonthDayYear
Date
Insurance Information (you may choose to send us an image of your card instead of filling out this section. Please send the front and back for verification purposes. If you choose to fill out the form, please include the primary policy holders SS#, DOB and relation to patient.)
Demographic. Check all that apply.*

MarriedSingleMinorMaleFemale
Name of Employer

First NameLast Name
Phone Number of Employer
Please enter a valid phone number.
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.
To whom we may thank for referring you to our office?
May we text or email you for appointment reminders? Select only.*

TextEmailYes, for bothNo (I understand that I will be responsible for any missed appointments and a late/ no show fee may apply per office policy)MaybeI like to talk to staff about specifics
Advanced Family Dentistry Cancellation Policy:

If you are unable to keep your scheduled appointment with Dr. Taler, please be courteous and provide a 48-hour notice to any change in the schedule. This is regarding cancellations or rescheduling. Failed appointments will have a charge of $50.00

Thank you for understanding!
Dr. Taler and Advanced Family Dentistry
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