Forms

To save time spent on paperwork, please print and complete the forms below and bring them to our dental Office or fax them to us at:

• North Bergen – 201 330 3333
• Passaic – 973 473 8188

• From
• English
• Spanish

• Patient Registration Form
  Once your appointment is confirmed, please print and complete this form, and bring it with you to our dental Office or fax it to us.
• Patient Information
• Patient Information

• Medical Health Questionnaire
  If you want to provide your medical health information to us (optional), please print and complete this form (to the extent you can), and bring it with you to our dental Office or fax it to us.

• HIPAA Consent Form
  By signing on this form, you agree to the use and disclosure of your health information for treatment purposes, payment activities and healthcare operations of our dental Office.
• HIPAA Consent Form

• Medical Record Release Form
  If you want to authorize the release of your medical records from your existing health care provider to us or someone other than yourself, please print and complete this form, and bring it with you to our dental Office or fax it to us.
• Medical Record Release Form

• Financial Agreement Form
  By signing on this form, you agree to the payment terms of our dental Office.
• Financial Agreement

• Acknowledgement-Receipt of Notice of Privacy Practices
• Acknoledgement-receipt of notice of privacy practices