Patient Forms

Patients new to our practice are asked to provide us with registration information that helps with all aspects of organization from simple record keeping to the more complex insurance billing procedures, when indicated. We also ask for dental and medical histories that help us to understand existing conditions in our effort to provide you with the best care possible.

We recommend downloading the form and filling it out on your computer. It may then be saved and emailed as an attachment to our main address at:

Alternatively you may print the form and bring it along to your appointment.

You may pick the form that best suits your system. The docx format is compatible with Microsoft Office programs and the pdf format is compatible with Adobe programs. Click on the two of your preferred format links below.

Registration Form.docx

Dental-Medical History Form.docx

At this time, the PDF version is not available.

To complete your forms online, click the button below to register using our online patient portal:


 This web site uses files in Adobe Acrobat Portable Document Format  (pdf) which require Adobe® Acrobat® Reader for viewing and printing. It is available to download free.R

Connect With Us


Contact Us

We encourage you to contact us with any questions or comments you may have. Please call our office or use the quick contact form below.

Ready to come in for an appointment?
Contact us today!

~Robert Berkenmeier, DDS ~ Janice Sugiyama, DDS ~

Carpinteria, California Dentist, Dr. Robert Berkenmeier is dedicated to cosmetic dentistry such as Exams, Teeth Whitening, Veneers and more.

Site Developed by