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Patient Forms

As a new patient or an existing patient, Northpark Dental provides this form section for your convenience as reference documents or as you prepare the forms requirements for your Dental Healthcare.  Feel free to contact us if you have any further questions about the forms or how to complete them correctly.

New Patient Forms package

1. Mandatory patient information

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New Patient form – Child

 

 

pdficonNew Patient Form – Adult

 

 

2. Insurance claim authorization

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Insurance claim authorization form

 

 

3. Notice of Privacy Practices

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Notice of Privacy Practices

 

 

4. Acknowledgement receipt of Notice of Privacy Practices

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Acknowledgement of Receipt of Notice Privacy Practices

 

 

5. Dental Material Facts

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Dental material fact sheet form

 

 

6. Acknowledgment receipt of Dental Material Facts

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Acknowledgement of Receipt of Dental Materials Fact Sheets