Our Patient paperwork is available online.
Please download the paperwork that you require.
You may fax any paperwork to Belknap Dental at (603) 742-9911
- Download New Patient Paperwork
- Download Records Release Form to transfer x-rays TO our office
- Download Records Release Form to transfer x-rays FROM our office
- Download Parent/Legal Guardian Consent for Treatment Form
- Download Personal Representative Designation Form
- Download 18 and over HIPAA and Personal Health Disclosure Form
- Download Personal Health Information Disclosure Agreement Only (must be signed for disclosure of information of anyone over 18 years of age)
For your first visit, we will need the following:
- Completely filled-out New Patient Paperwork
- Insurance information and an insurance card available to scan or copy
- If pre-medication is required, please take the appropriate dose as prescribed by your medical doctor before visit.
This is an extended visit reserved for you. If you need to change this appointment, please give us 24 hours notice.We can then offer the appointment to another patient. Thank you for your cooperation and thoughtfulness.
Directions to 40 Chestnut Street, Suite 2 Dover , NH 03820 US
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