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 Complete and Send button at the bottom to automatically send us your information.

The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

Save & Exit buttonNote to Patient: Upon filling out your first name, last name, email and at least one phone number field (a valid home or cell phone) a button will appear in the upper right corner titled “Save and Exit“.

This button allows you to save and exit your form to complete at a later date. The system will send a registration email to the email provided on the form, so that you may setup a login to go back and finalize your registration form online.

Online Patient Registration

By filling out our patient registration form in advance, we are able to provide you with a faster and more convenient experience upon your first visit to our office. If you have any questions about the patient registration process, please call us at Jacks Oral Surgery & Dental Implants Office Phone Number 937-778-1623.

Office Hours

Monday:   8:00 AM - 4:00 PM
Tuesday:   8:00 AM - 5:00 PM
Wednesday:   8:00 AM - 1:00 PM
Thursday:   8:00 AM - 5:00 PM
Friday:   8:00 AM - 1:00 PM


Patient Links of Interest

Thank you for choosing Jacks Oral Surgery & Dental Implants. We strive to deliver the best diagnosis and treatment that our practice has to offer. We believe that these goals can be met through a continuous and open dialogue between you and our entire team. Please contact us if you have any questions.

Are You Ready To Schedule Your Care?

Call us: 937-778-1623