Dental Clinic Information System

Create Patient Account

Patient Type: * Faculty covers teaching personnel. Staff covers non-teaching personnel.

ID Number: * Students enter their Student ID. Faculty and staff enter their Employee ID. This will be your login username.

First Name: *

Middle Name:

Last Name: *

Age: *

Sex: *

Campus: *

Course: *

Year Level: *

Section: *

Department or Office: *

Position or Designation: *

Contact Number: *

Address: *

Email Address: *

2x2 ID Picture: * Upload a clear ID photo (JPG or PNG)

Password: * Use 8 to 15 characters. Mix letters, numbers and at least one symbol such as ! @ # $ % & * ? - _
Good: Dental@2026 Weak: password123
Do not reuse your Student ID, your birthday or your name.

Confirm Password: *

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