Click on Calendar, type the year "YYYY" and pick the month & date.
I moved three hours away, but I
insist on making the special trip to
Dr. Hellickson every 6 months. He
and his staff are the best!
Bradi Yaggie
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New Patient Registration

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Please note that it is important to fill in all the fields before submitting. Thank you.

Is the appointment for you your Child

About You
*Your Name :
*Last Name

Middle Name
*First Name
I prefer to be called : Social security # :
*Your birthday :
Age: Sex : MaleFemale
*Home address :
*City
 *State
*Zip
 APT#
*Email address :
Marital Status : Single    Married    Divorced    Widowed
*Home Phone : ()- -
Fax number : ()- -
Cell Phone : ()- -

Dental Insurance
Primary carrier
Insurance company :
Group number :
Employer name :
Insured’s name :
Insured's I.D.# :
Birthday :
Relationship :
Insured's Social security # :
Secondary carrier
Insurance company :
Group number :
Employer Name :
Insured’s name :
Insured’s I.D.# :
Birthday :
Relationship :
Insured’s Social security # :

Getting to know you
Is Another member of your family or relative a patient at our office?
Family member Name :
Relationship :
How did you hear about us? Have you visited our website? Yes No
Whom may we Thank for referring you?
Former Address :
City State
Zip
 APT#
Person to contact for emergency
Contact name : Phone number : ()- - 
Address :
City State
Zip
 APT#
Closest relative not living with you
Name : Phone number : ()- - 
Address :
City State
Zip
 APT#

Account information
Person financially responsible for account
Name :
Relationship to patient :
Address :
City State
Zip
 APT#
Phone number : ()- - 
Insured’s Social security # :
You
Name :
Occupation:
Employer's Name :
Address :
City State
Zip
Phone number : ()- - 
Fax number : ()- - 
Your spouse
Name :
Occupation :
Employer's name :
Address :
City State
Zip
Phone Number : ()- - 
Fax Number : ()- - 

Consent for treatment
  1. I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of dental needs.
  2. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
  3. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
  4. I give consent to the doctor’s or designated staff’s use and disclosure or any oral, written or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and health care operations. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information is available.
  5. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1-1/2% late charge (18% ARP) may be added to my account. If required, I also understand a check of my credit history may be made.

*Patient/Parent/Responsible Party’s Signature :
Relationship to Patient : Date :
Witness :
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Advanced Dental Group Located at 3909 Silver Lake Rd., St. Anthony, Minneapolis 55421.
Phone: 888-993-1449. .