Valparaiso Location


(219) 307-4382
(219) 462 9599


(219) 600-5797
(219) 736 1401
Request an appointment Two female friends laughing

Patient Registration

Home >> Patient Registration
Please note below step by step instructions are mandatory to be followed in order to complete the forms successfully

  • STEP 1: Download the form to your device.
  • STEP 2: Open the downloaded form in an Adobe Acrobat Reader. (Do not open the form in your browser)
  • STEP 3: Fill the form and save it to your device.
  • STEP 4: Attach the saved document to the email address below and send it to us / Print out the completed form, and bring it along when you visit us.

Email address:

Before & After

view more

Left quote

google review by Leah A

I just had my 2 wisdom teeth extracted this morning and went with the Nitrous Oxide and IV Sedation by Dr. Surber. I was so so anxious especially because it was my first time ever having an IV. Dr. Surber and his assistants made me feel so comfortable!

The laughing gas helped calm me down and the IV didn’t even hurt. I was out so fast and seems like I just woke up in a blink! Doctor Surber came in the recovery room to check on me and off I went! Thank you for making me feel at ease, would definitely recommend!

Leah A
Originally Posted on Reviews Posted on Google
read more