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.

Patient Registration Form

Technical Note:

PC Users
Our online form uses the latest version of Adobe Acrobat Reader 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.

Mac Users
You must open and submit the form in a Safari Browser with the latest Mac operating system. It is also important to have the latest version of Adobe Acrobat Reader on your computer in order to submit your form to our office correctly, please download the free plug-in from Adobe’s web site.

The Oral Surgeons of Northern Vermont Oral & Facial Surgery are Dr. Bradford Towne, Dr. William Purdy, Dr. Jeffrey Glosser, Dr. Robert Lesny,
with offices located in Essex Jct., Berlin, St. Albans & St. Johnsbury, serving patients throughout Northern Vermont.
Procedures include: Dental Implants, Wisdom Teeth Extraction, Jaw Surgery, Bone Grafting & Cosmetic Procedures.
Address: 8 Carmichael Street • Essex Jct., VT 05452 • Telephone: 802-872-3593 • Fax: 802-872-9691
Address: 17 Catherine Street • St. Albans, VT 05478 • Telephone: 802-524-0490 • Fax: 802-527-7803
Address: 310 Fisher Road • Suite 1 • Berlin, VT 05602 • Telephone: 802-223-2364 • Fax: 802-223-9691
Address: 1 Place Notre Dame • Suite 2 • St. Johnsbury, VT 05819 • Telephone: 802-473-4150 • Fax: 802-473-4152