All forms can be mailed to:

 

Go! Dental Services

Regional HQ

25 Central Park West

Suite 1Y

New York, NY 10023

 

Faxed to 1-800-715-9211

 

Or emailed to info@go-dentalservices.com

 

 

 

New Patient Paperwork

 

We have all of our forms available online for your convenience. Simply select the appropriate community, print and complete the forms, and return to our regional headquarters. The forms are accessible only with a password. Please call our office if you have any questions or trouble.

 

 

Patient Information:

This form contains necessary information on the resident/patient and the person(s) responsible for their health care decisions and finances.

If you are: 

• The family member, friend, Power of Attorney, or person handing the patient's finances and/or health care decisions: please fill out their information where appropriate, and then your information under the 'Responsible Party' heading. It is important you include as much contact information as possible.

• The resident and you handle all of your own finances and health care decisions: please complete this form including your information under the 'Responsible Party' heading, and information on a family member or close friend whom we may contact in the event of an emergency under the 'Emergency Contact' heading.

 

Medical History

Please complete this form as accurately as possible. It is very important to include the name and phone number of the patient's/your Primary Care Physician. If you have any questions please contact us. 

 

Financial & Informed Treatment Consent

By signing this form you authorize our doctors to treat you or your loved one to the services agreed upon and to the best of their ability. This form explains our financial policies, and you may select your preferred billing method. 

 

HIPPA Privacy Policy and Acknowledgement

These forms contain both the HIPPA Privacy Policy packet, and the Acknowledgement form. Only the Acknowledgement form needs to be signed and returned to Go! Dental Services; the Policy packet is for your review and records.