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 or bring with you.
- Download New Patient Paperwork
- Dowload Patient Medical UPDATE Form (for EXISTING patients ONLY)
- 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)
You may email to firstname.lastname@example.org or print and bring with you.
Please download to your desktop, fill out questions and then save it. If you click on Fill & Sign on right side of the screen, the signature pen will usually be on top to make it easy to sign. After finishing, please save and email to email@example.com or print and bring with you.
- Download Electronic New Patient Paperwork **Can be signed at appointment**
- Download Electronic Updated Medical History Paperwork **Can be signed at appointment**
- Download Electronic Records Release Form to transfer x-rays FROM our office
- Download Electronic Parent/Legal Guardian Consent for Treatment Form
- Download Records Release Form to transfer x-rays TO our office **After finishing, please save and email to the previous dentist.**
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.