Forms

Please complete all forms. Once we receive completed forms our office will call you to schedule initial appointments.

Please note, we are NOT in network with the following Medicaid divisions: Anthem and MDWise

Thank you for choosing North Point Pediatric Dentistry. Please follow the link below to a secure portal to complete, review and sign all necessary documents. By law, we are required to have this information on file in order to treat your child/children.

All documentation must be completed by a parent or court appointed legal guardian, no exceptions. Failure to complete all necessary forms may require information to be completed once again, in office. If you have any questions, please contact our office and we will be happy to help you.

PLEASE NOTE: If you are not filing insurance with Indiana Medicaid, please leave the last form blank but sign where indicated. It will not be attached to your account but it is necessary to submit the package of forms electronically.

Choose a location

SOUTH BEND

New Patient Forms

We are currently accepting patients ages 10 and under.

Referral Patient Forms

Update Patient Forms

Forms for Legal Guardians

Note to Parents & Legal Guardians:
If you, as a parent or legal guardian, need to authorize someone to bring your child to an appointment or make any decisions regarding care, please fill out this form below. Notice, you must be parent or legal guardian to fill out this form.

(Spanish) Si usted, como padre o tutor legal, necesita autorizar a alguien mas a llevar a su hijo/a a una cita o tomar cualquier decisión con respecto a la atención dental, completa este forma que sigue. Aviso, debe ser padre o tutor legal para completar este forma.

Forms

Choose a location

SOUTH BEND

New Patient Forms

Referral Patient Forms

Update Patient Forms

Forms for Legal Guardians

Release of Records

ELKHART

New Patient Forms

Referral Patient Forms

Update Patient Forms

Forms for Legal Guardians

Release of Records

Locations

South Bend

Elkhart