Urgent Dental Care of New Hampshire

New Patient Forms

Save time in our office by filling our new patient registration forms online. We offer our patient registration forms in 2 formats for our patients.

1). The first format just below in the white box is for MANCHESTER PATIENTS ONLY. This will redirect our patients to another site where they can digitally fill out all their registration paperwork without having to print.

2). The Second format is below in the gray boxes which allows patients to print and manually fill out the forms for both Manchester and Somersworth locations.

 

 

VA Patient Eligibility Form

Patient Registration Form - Manchester

Patient Registration Form - Somersworth

HIPAA Policy All Offices - READ ONLY

Have Questions? Get in Touch
If you have difficulty using our website, please email us or call us at (603) 627-3927
View the ADA Accessibility Statement
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 implementation of protocols that will slow down treatment and patient flow and we kindly request everyone’s patience and cooperation with these necessary changes. If we are unable to see patients in our Manchester location in a timely fashion, we may refer them to our Somersworth location for treatment, which is also functioning on a reduced staff and schedule.
 
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
For our Manchester patients, you will be required to fill out your patient registration paperwork online and you can follow this link to do so: 

https://forms.patientconnect365.com/10597