dentists in Hutchinson KS, Grant Ringler DDS, general and cosmetic dentistry

Forms - New Patient Application

Welcome to the secure on-line New Patient Application System.

Take the time you need to fill out the form. After you submit the form, you may use the "back" button on your web browser to review, correct and resubmit the form as many times as you like, until you close your browser. Resubmitting the form will overwrite previous submissions with the updated information.

When you are finished, please print a copy of the form for your records.

The information is encrypted and secure on the web server. It is not stored on the server and will be removed by The Ultimate Dental Experience staff upon receipt.

New Patient Application Form

Phone:
620.669.0835
888.OPN.WIDE

Fax:
620-669-8740

Email:
info@opnwide.com

Off-line applications forms are also available for your convenience. The first is the new patient form and the second a financial agreement. The first form may be filled out on your computer and printed. The second form should be printed and signed. Both forms need to be faxed, mailed or brought with you to your appointment.

New Patient Form (PDF)

Financial Policy Agreement (PDF)

Please feel free to contact Dr. Ringler at info@opnwide.com

3008 Garden Grove Parkway, Hutchinson, Kansas 67502
620.669.0835 - 888.OPN.WIDE

info@opnwide.com