Patient Registration - Bergens Periodontics & Implant Dentistry

Daytona Beach | (386) 258-2213
Palm Coast | (386) 447-5846
DeLand | (386) 738-0313
MAKE AN APPOINTMENT

You may preregister with our office by printing out our registration form below. Please bring this with you to your first visit.

Patient Registration Form

Patient Information

FAQs

Links

Accreditation

@font-face{font-family:eicons;src:url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/source/rev-9e143e0/wp-content/plugins/elementor/assets/lib/eicons/fonts/487fb88d73d41a26c611d95e94cc95a3.eicons.eot");src:url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/source/rev-9e143e0/wp-content/plugins/elementor/assets/lib/eicons/fonts/487fb88d73d41a26c611d95e94cc95a3.eicons.eot#iefix") format("embedded-opentype"),url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/source/rev-9e143e0/wp-content/plugins/elementor/assets/lib/eicons/fonts/487fb88d73d41a26c611d95e94cc95a3.eicons.woff2") format("woff2"),url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/source/rev-9e143e0/wp-content/plugins/elementor/assets/lib/eicons/fonts/487fb88d73d41a26c611d95e94cc95a3.eicons.woff") format("woff"),url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/source/rev-9e143e0/wp-content/plugins/elementor/assets/lib/eicons/fonts/487fb88d73d41a26c611d95e94cc95a3.eicons.ttf") format("truetype"),url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/optimized/rev-9e143e0/wp-content/plugins/elementor/assets/lib/eicons/fonts/487fb88d73d41a26c611d95e94cc95a3.eicons.svg#eicon") format("svg");font-weight:400;font-style:normal;font-display:swap;}@font-face{font-family:"FontAwesome";src:url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/source/rev-9e143e0/releases/v5.15.3/webfonts/fa-brands-400.eot"),url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/source/rev-9e143e0/releases/v5.15.3/webfonts/fa-brands-400.eot#iefix") format("embedded-opentype"),url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/source/rev-9e143e0/releases/v5.15.3/webfonts/fa-brands-400.woff2") format("woff2"),url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/source/rev-9e143e0/releases/v5.15.3/webfonts/fa-brands-400.woff") format("woff"),url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/source/rev-9e143e0/releases/v5.15.3/webfonts/fa-brands-400.ttf") format("truetype"),url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/optimized/rev-9e143e0/releases/v5.15.3/webfonts/fa-brands-400.svg#fontawesome") format("svg");font-display:swap;}@font-face{font-family:"FontAwesome";src:url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/source/rev-9e143e0/releases/v5.15.3/webfonts/fa-solid-900.eot"),url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/source/rev-9e143e0/releases/v5.15.3/webfonts/fa-solid-900.eot#iefix") format("embedded-opentype"),url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/source/rev-9e143e0/releases/v5.15.3/webfonts/fa-solid-900.woff2") format("woff2"),url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/source/rev-9e143e0/releases/v5.15.3/webfonts/fa-solid-900.woff") format("woff"),url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/source/rev-9e143e0/releases/v5.15.3/webfonts/fa-solid-900.ttf") format("truetype"),url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/optimized/rev-9e143e0/releases/v5.15.3/webfonts/fa-solid-900.svg#fontawesome") format("svg");font-display:swap;}@font-face{font-family:"FontAwesome";src:url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/source/rev-9e143e0/releases/v5.15.3/webfonts/fa-regular-400.eot"),url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/source/rev-9e143e0/releases/v5.15.3/webfonts/fa-regular-400.eot#iefix") format("embedded-opentype"),url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/source/rev-9e143e0/releases/v5.15.3/webfonts/fa-regular-400.woff2") format("woff2"),url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/source/rev-9e143e0/releases/v5.15.3/webfonts/fa-regular-400.woff") format("woff"),url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/source/rev-9e143e0/releases/v5.15.3/webfonts/fa-regular-400.ttf") format("truetype"),url("https://cdn-aofoa.nitrocdn.com/NjXNMwCkWlhsHxhjFjWLKsuQEhosIjqg/assets/static/optimized/rev-9e143e0/releases/v5.15.3/webfonts/fa-regular-400.svg#fontawesome") format("svg");unicode-range:U+F004-F005,U+F007,U+F017,U+F022,U+F024,U+F02E,U+F03E,U+F044,U+F057-F059,U+F06E,U+F070,U+F075,U+F07B-F07C,U+F080,U+F086,U+F089,U+F094,U+F09D,U+F0A0,U+F0A4-F0A7,U+F0C5,U+F0C7-F0C8,U+F0E0,U+F0EB,U+F0F3,U+F0F8,U+F0FE,U+F111,U+F118-F11A,U+F11C,U+F133,U+F144,U+F146,U+F14A,U+F14D-F14E,U+F150-F152,U+F15B-F15C,U+F164-F165,U+F185-F186,U+F191-F192,U+F1AD,U+F1C1-F1C9,U+F1CD,U+F1D8,U+F1E3,U+F1EA,U+F1F6,U+F1F9,U+F20A,U+F247-F249,U+F24D,U+F254-F25B,U+F25D,U+F267,U+F271-F274,U+F279,U+F28B,U+F28D,U+F2B5-F2B6,U+F2B9,U+F2BB,U+F2BD,U+F2C1-F2C2,U+F2D0,U+F2D2,U+F2DC,U+F2ED,U+F328,U+F358-F35B,U+F3A5,U+F3D1,U+F410,U+F4AD;font-display:swap;}.whole-form{display:flex;}.submit-btn{padding:25px 30px;}::-webkit-input-placeholder{color:#2d3436 !important;opacity:.6;font-size:14px;}.footer-nav p{margin:0;}.footer-nav p a{font-size:15px;}#menu-main-menu .appointment-btn a{background:#ee5253;color:white !important;border-radius:50px !important;}#site-navigation-wrap .dropdown-menu>li>a{line-height:45px !important;}#site-header{border-bottom:none;}#site-header #site-logo #site-logo-inner a img,#site-header.center-header #site-navigation-wrap .middle-site-logo a img{max-height:500px;margin-top:-22px;padding-top:0;}ul.top-address li{display:inline;}ul.top-address{margin:0;padding-top:15px;}@media only screen and (max-width:900px){ul.top-address li.address-1{display:inline;}ul.top-address li.address-2{display:none;}ul.top-address li.address-3{display:none;}.page-id-863 ul.top-address li.address-1{display:none;}.page-id-863 ul.top-address li.address-2{display:inline;}.page-id-863 ul.top-address li.address-3{display:none;}.page-id-868 ul.top-address li.address-1{display:none;}.page-id-868 ul.top-address li.address-2{display:none;}.page-id-868 ul.top-address li.address-3{display:inline;}.elementor-26 .elementor-element.elementor-element-de89e05 .bdt-prime-slider .bdt-prime-slider-desc .bdt-main-title .bdt-title-tag{font-size:15px;}.bdt-slideshow-item .bdt-cover{position:absolute;top:50% !important;}.oceanwp-mobile-menu-icon a{color:#eee;}}#footer-bottom #footer-bottom-menu ul{display:none !important;}#footer-widgets .footer-box .widget-title{color:#000;font-size:14px;font-weight:600;}.contact-info-widget span.oceanwp-contact-text:hover{color:#fff;}.contact-info-widget.default i{border:none;font-size:25px;color:#e17055;margin-top:-8px;}.textwidget{text-align:justify;padding-right:20px;}#footer-bottom{padding:15px 0 !important;}.top-address li{font-size:18px;}#mysticky-nav.wrapfixed{background-color:#2980b9;}#top-bar-wrap{border-bottom:1px solid rgba(241,241,241,.33);}#site-header{background-color:#2980b9;}#menu-main-menu li a{font-size:17px !important;color:#fff !important;padding:0 10px;}#menu-main-menu li ul li a{font-size:17px !important;color:#000 !important;line-height:40px !important;}#footer-widgets{background-color:#2980b9 !important;border-bottom:1px solid rgba(241,241,241,.33);}#footer-widgets .footer-box .widget-title{color:#fff;}#menu-main-menu .appointment-btn a{background:#eee;color:#555 !important;border-radius:50px !important;}div#n2-ss-2 .n2-font-eab51c91a105da89340da7933c600fd4-link a{color:#333 !important;background:#eee;}.sf-menu ul.sub-menu{width:300px;}.elementskit-single-testimonial-slider .elementskit-commentor-image img{display:none;}.ekit-wid-con .elementskit-commentor-bio .elementskit-commentor-image >img{display:none;}.ekit-wid-con .elementskit-testimonial-slider-block-style-two .elementskit-stars{margin:auto;}.elementor-shortcode p label{color:#eee;}#intro_sec a{color:#2980b9;}#intro_sec p{font-family:inherit;font-size:1.4em;}#mysticky-nav.wrapfixed{opacity:1;}#home_name_tag h1{font-size:2em;}@media only screen and (max-width:500px){#site-logo #site-logo-inner a img,#site-header.center-header #site-navigation-wrap .middle-site-logo a img{max-width:200px !important;}ul.top-address .make_top{display:block !important;}#top-bar{padding:5px !important;}ul.top-address .make_top{position:relative;line-height:4em;}#top-bar{height:120px;}#site-header{top:12% !important;}.head_center{margin-left:12% !important;}.bdt-title-tag{margin-left:5% !important;}.loc_header_mob .elementor-heading-title{font-size:15px !important;line-height:26px !important;}.cards{display:unset !important;}}@media only screen and (min-width:501px) and (max-width :700px){#site-logo #site-logo-inner a img,#site-header.center-header #site-navigation-wrap .middle-site-logo a img{max-width:225px !important;}}@media only screen and (min-width:701px) and (max-width :1440px){#site-logo #site-logo-inner a img,#site-header.center-header #site-navigation-wrap .middle-site-logo a img{max-width:250px !important;}}.page-id-2462 p{}.page-id-2462 .elementor-widget:not(:last-child){}#bergens-slider .elementor-column-wrap{padding:0;}#menu-main-menu .appointment-btn a{border-radius:3px !important;}#menu-main-menu .appointment-btn a:hover{background:#bf393a;}.effect-one #site-navigation-wrap .dropdown-menu >li >a.menu-link >span::after{background:transparent;}.effect-one #site-navigation-wrap .dropdown-menu >li >a.menu-link >span:hover{color:#fff;}#site-header{position:sticky;width:100%;top:44px;}.bdt-cover{position:absolute;top:66% !important;}.elementor-336 .elementor-element.elementor-element-5e8d7831 .elementskit-profile-info{text-align:center;}.cards{display:grid;grid-template-columns:1fr 1fr 1fr;grid-gap:10px;}.card{}.cards{margin:0 auto;max-width:960px;}.card{background-color:#fff;box-shadow:0 2px 2px 0 rgba(0,0,0,.14),0 3px 1px -2px rgba(0,0,0,.2),0 1px 5px 0 rgba(0,0,0,.12);}.card header{padding:10px;background-color:#0084ad;color:#fff;}.card header h2{font-size:1.4rem;font-weight:normal;color:#eee;margin:0;padding:0;}.card .body{padding:10px;font-size:18px;font-weight:500;color:#000;}#site-navigation-wrap .dropdown-menu >li >a{padding:10px 5px !important;}#site-navigation-wrap .dropdown-menu #menu-item-974 .menu-link{padding:5px 8px !important;margin-top:2%;}#menu-main-menu .appointment-btn a{background:#ee5253;color:#fff !important;}.appointment-btn a span{text-transform:uppercase;}.bdt-position-large{margin-top:20%;}.envato-block__preview{overflow:visible;}.envato-block__preview{overflow:visible !important;}.mr-10{margin-right:5%;}ul.top-address .make_top{display:none;}.make_top a{padding:10px;font-size:16px;cursor:pointer;background-color:#d9534f;color:#fff;}footer #ocean_contact_info-4 .address span.oceanwp-contact-text{width:165px;}#intro_sec .elementor-widget-container{width:100%;}#intro_sec h1{margin-right:18%;}.head_center{text-align:center;}.head_center1{text-align:center;font-size:25px;}.head_center2{text-align:center;font-size:35px;}.callto_action button{background:#ee5253;color:#fff !important;font-size:18px;font-weight:normal;border:none;padding:7px 25px;box-shadow:2px 2px rgba(156,3,3,.1);border-radius:3px !important;text-transform:uppercase;letter-spacing:.6px;width:32%;margin-left:auto;margin-right:auto;display:block;}#footer-widgets .container{width:1526px !important;}.callto_action button:hover{background:#bf393a;}.youtube_vid{margin-left:24%;margin-bottom:3% !important;}.popmake-2893 .elementor-widget-container .elementor-button-wrapper .elementor-button{background-color:#ec3f13;}#menu-main-menu .appointment-btn a{background:#ec3f13;}.callto_action button{background:#ec3f13;}@media (min-width:768px) and (max-width:1024px){#intro_sec h1{margin-right:10%;}.head_center1{font-size:20px;width:100%;}.head_center2{text-align:center;font-size:25px;width:100%;}}@media only screen and (max-width:767px){.callto_action button{margin-left:4%;}.head_center1{font-size:20px;width:38%;}.head_center2{text-align:center;font-size:30px;width:38%;}}form label{color:#fff;font-weight:500 !important;}#footer-bottom #footer-bottom-menu,#footer-bottom #copyright{width:100%;}@media only screen and (max-width:500px){#site-header{top:17% !important;}}.nf-form-content button,.nf-form-content input[type=button],.nf-form-content input[type=submit]{background:#ec3f13 !important;border-radius:3px !important;color:#fff !important;cursor:pointer;}.nf-form-content button:hover,.nf-form-content input[type=button]:hover,.nf-form-content input[type=submit]:hover{background:#bf393a !important;}.nf-form-fields-required{color:#ececec;}