Keith Chertok, DDS
Berkeley, CA
Call Today!
(510) 548-0150
  • Home
  • PATIENT INFORMATION
    • Introduction
    • First Visit
    • Scheduling
    • Financial Policy
    • Insurance
    • Patient Registration
    • Online Payment Form
  • Testimonials
  • PERIODONTAL DISEASE
    • Periodontal Care
    • About Periodontal Disease
    • Preventing Gum Disease
    • Oral Hygiene
    • Oral Pathology
  • SERVICES
    • Treatment Methods
    • Scaling and Root Planing
    • LANAP™ Laser Periodontal Procedures
    • Dental Implants
    • Teeth-in-an-Hour
    • Cosmetic Periodontal Surgery
    • Gum Grafting
    • Crown Lengthening
    • Osseous Surgery
    • Bone Regeneration
    • Bone Grafting
    • Ridge Preservation
    • Sinus Lifts (Sinus Augmentation)
    • Prophylaxis
    • Bruxism Treatments
    • Perioscopic Treatment
    • Bite Adjustment
    • Frenectomy
    • Oral Cancer Exam
    • Stem Cell Recovery
    • Piezosurgery
  • REFERRING DOCTORS
    • Referral Form
    • Links of Interest
  • MEET US
    • Meet Us
  • CONTACT US
    • Contact Information / Office Map

Online Patient Registration

You may preregister with our office by filling out our secure online Patient Registration Form. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information. On your first visit to our office, we will have your completed form available for your signature. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

Technical Note: *Once reviewed, scroll down to the bottom to submit this online patient registration form.

MAC Users **Required
CLICK HERE for step by step instructions before proceeding to register with our office!

PC Users

Our online form uses Adobe Acrobat Reader 9 or greater plug-in to conveniently submit the form from home or work. Please download the free plug-in from Adobe’s web site if it is not already installed on your system. It is important that you have at least version 9 of the plug-in to successfully use our online form.

 

Please print and fill out the forms below, please make sure to bring with you at the time of your appointment

  • HIPAA Acknowledgement form
  • Financial/Payment Policy Form

 

PATIENT INFORMATION

  • Introduction
  • First Visit
  • Scheduling
  • Financial Policy
  • Insurance
  • Patient Registration
  • Online Payment Form
  • Home
  • PATIENT INFORMATION
  • Testimonials
  • PERIODONTAL DISEASE
  • SERVICES
  • REFERRING DOCTORS
  • MEET US
  • CONTACT US
  • Disclaimer
  • Sitemap

East Bay Periodontist serves the following communities including
Berkeley CA • Oakland CA • Emeryville CA • Alameda CA • El Cerrito CA
San Leandro CA • Moraga CA • Piedmont CA • Orinda CA • Albany CA
Montclair and Kensington CA

Address: 2620 Ashby Avenue, Suite 101, Berkeley, CA 94705 • Phone: (510) 548-0150 • Fax: (510) 548-0156

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