Good Life Dental, PC
New Patient Registration
302 S Bailey Ave, North Platte, Nebraska 69101
(308) 532-0427
Please complete this packet and bring it to your first appointment. To protect your privacy, do not send completed forms electronically.
1Patient Information
2Emergency Contact
3Dental Insurance
No insurance? No problem — ask us about payment options and our same-day payment discount.
4Dental History
Do any of these apply to you?
Feeling nervous? Check “dental anxiety” above — ask us about nitrous oxide to keep your visit calm and comfortable.
5Medical History
Please check any conditions that apply:
6Consent & Financial Policy
I certify that the information above is accurate to the best of my knowledge. I authorize Good Life Dentalto perform the dental care I agree to, and I understand I am responsible for charges not covered by my insurance. I acknowledge receipt of the practice's Notice of Privacy Practices (HIPAA).
Good Life Dental, PC · 302 S Bailey Ave, North Platte, Nebraska 69101 · (308) 532-0427 — We look forward to meeting you!
Tip: choose “Save as PDF” in the print dialog to keep a digital copy.