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New Patient Registration & Health History

Complete one packet for your first visit, including registration, dental history and medical history. Download the fillable PDF or prepare it online, then print and bring it to your appointment.

· Patient & Contact Information
· Insurance Information
· Dental History & Concerns
· Medical History
· Medications & Allergies
· Consent for Care & Financial Policy
Download Fillable PDF · 4 pagesRead & Fill Out Online

Your online entries stay on this page and are not submitted to the practice. Print or save your completed packet, then bring it to your appointment.

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The NS UPFRONT™ Contract (Financial Policy)

The NS UPFRONT™ Contract brings our financial policy and mutual commitments together in one place. Review fees, insurance coordination, payment options, and the responsibilities of both our practice and our patients before your visit.

· Treatment Plan Agreement
· Fee Disclosure
· Insurance Assignment of Benefits
· Co-Payment Policy
· Payment Plan Options
· Cancellation Policy
· Outstanding Balance Policy
· Accepted Payment Methods
· Patient Responsibilities
· Practice Responsibilities
· Communication Expectations
· Right to Modify Treatment
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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
· Acknowledgment of Receipt
· Confidential Communications
· Personal Representative Rights
· Right to Access Records
· Complaint Procedures
Download Fillable PDFRead Notice & Fill Out Online

Complete in your browser, print, sign and bring to your appointment. Entries are not submitted online. This acknowledgment does not authorize release of records.

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.

Contact Us