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Patient Forms

Adult New Patient Forms: 

New Patient Paperwork (Word Document) or New Patient Paperwork (PDF)

Family New Patient Forms: 

Families with multiple children please fill out our new patient family form below with a medical history for each person:

New Patient Family Paperwork (Word Document) or New Patient Family Paperwork (PDF)

Medicaly History Form (Word Document) or Medical History Form (PDF) Only 1 medical history per person is needed.

The forms include:

  • Patient Registration & Medical History
  • Financial Policies
  • Privacy Policy
  • Photo Consent

We ask that you fill out the forms prior to your arrival of your first visit with us. You may email them to info@premiersmile.com to expedite the checkin process.

If you have any questions regarding the forms or need any assitance, please call the office at 402-718-8737.

We look forward to seeing you!

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