Patient Forms | NorthStar Implant Dentistry

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Registration Form

New patients please complete the registration form prior to your first visit. This helps us set up your patient profile and ensure a smooth check-in experience.

· Full Legal Name

· Date of Birth

· Address

· Phone Number

· Email Address

· Emergency Contact

· Insurance Information

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Medical History Form

A complete and accurate medical history is essential for safe dental care. Please list all current medications, allergies, and medical conditions.

· Current Medications

· Known Allergies

· Medical Conditions

· Previous Surgeries

· Primary Care Physician

· Blood Pressure / Heart Conditions

· Diabetes / Bleeding Disorders

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Dental History Form

Your dental history helps our team understand your previous care, any concerns you have, and how to best approach your treatment.

· Last Dental Visit

· Previous Dentist

· Past Dental Procedures

· Dental Anxiety Level

· Chief Complaint / Reason for Visit

· Previous Implants or Extractions

· Current Dental Concerns

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Financial Policy

Please review our financial policy before your appointment. We are committed to transparency around fees, insurance coordination, and payment options.

· Insurance Assignment of Benefits

· Co-Payment Policy

· Payment Plan Options

· Cancellation Policy

· Outstanding Balance Policy

· Accepted Payment Methods

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The UPFRONT Contract

The UPFRONT Contract outlines the mutual commitments between NorthStar Implant Dentistry and our patients — ensuring clarity, transparency, and trust from the very first visit.

· Treatment Plan Agreement

· Fee Disclosure

· Patient Responsibilities

· Practice Responsibilities

· Communication Expectations

· Right to Modify Treatment

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Consent Forms

Informed consent forms are required before any surgical or procedural treatment. Please read carefully and ask any questions before signing.

· Surgical Consent

· Anesthesia / Sedation Consent

· Implant Placement Consent

· Extraction Consent

· Risks & Alternatives Acknowledgment

· Post-Operative Instructions Acknowledgment

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HIPAA Policy

Your privacy is our priority. Our HIPAA Notice of Privacy Practices explains how your personal health information is collected, used, and protected.

· Notice of Privacy Practices

· Authorization to Release Records

· Preferred Contact Method

· Authorized Representatives

· Right to Access Records

· Complaint Procedures

Need help completing your forms?

Our team is happy to assist you. Call us at any of our three locations or stop by the office.