Patient Pre-Registration — Bathina Endodontics

Patient information.

Fields marked with * are required. Your information is kept confidential and used only for scheduling and treatment planning.

Full Name *

Date of Birth *

Phone Number *

Referring Dentist *

Dentist Practice Name

Insurance Provider We are an out-of-network provider. We'll help you understand your benefits.

Member ID

Reason for Visit / Chief Complaint *

Preferred Appointment Date

Medications or Medical Conditions

Referred by your dentist?

This form helps us prepare for your visit. After you submit, our team will reach out within 1 business day to confirm your appointment.

What to Bring

Please bring your referral slip (if applicable), current dental X-rays or CBCT scans, a list of current medications, and your dental insurance card. Arrive 15 minutes early to complete any remaining paperwork.

Insurance & Fees

We are a fee-for-service practice — we do not participate in insurance networks. We file your claim as a courtesy and reimbursements go directly to you, typically within 10–14 days. We verify your benefits before your appointment so you know the cost upfront.

Need to Call Instead?

Prefer to register by phone? Call us at (512) 000-0000 and we'll get you set up.

Pre-register for your first visit.

Patient information.

Referred by your dentist?

What to Bring

Insurance & Fees

Need to Call Instead?

We look forward to caring for you.