Urgent Dental Care of New Hampshire

Online Digital Registration Forms

For safety and efficiency, we have made our Patient Registration forms available online. Please follow the links below to digitally fill out your forms:

 

FOR MANCHESTER PATIENTS, PLEASE FOLLOW THIS LINK

FOR SOMERSWORTH PATIENTS, PLEASE FOLLOW THIS LINK

 

If for some reason you are unable to fill out your forms online as we are requesting, and instead you need to download the PDF version and print them, you may do so by downloading and printing your forms below. 

Patient Registration Form - Manchester

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Patient Registration Form - Somersworth

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HIPAA Policy All Offices - READ ONLY

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VA Patient Eligibility Form

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Dear Patients,
Due to the COVID-19 Pandemic, we are currently operating with a reduced staff and restricted schedule. While treating patients we are taking necessary measures to ensure everyone’s safety. This requires the implementation of protocols that will slow down treatment and patient flow and we kindly request everyone’s patience and cooperation with these necessary changes.

We kindly ask that you inform us if you are experiencing any of the following symptoms:
  • Fever
  • Chills
  • Cough
  • Shortness of Breath
  • Sudden loss of Taste and Smell
  • Sudden Muscle/Body aches
  • Sore throat
  • Headache persisting longer than 24 hours
  • Nausea, Vomiting, Diarrhea
For safety and efficiency, patients will be asked to fill out digital registration forms online rather than using paper forms in person. Please use the following links depending on which practice you will be going to:

For MANCHESTER Patients Please Use This Registration Link:

For SOMERSWORTH Patients Please Use This Registration Link: