Dr. Steven Polisuk, DDS
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Patient Forms & Information

Patient Registration and Medical History
This form is used for new patients who will be visiting us for the first time. Please fill this out as completely as possible and bring it with you when you visit us for your first appointment. You can download and print the form by clicking here or by clicking on the form title.

Patient Acknowledgement and Consent Form
This form is required in order for us to provide you with care. Please print out this form and sign and date it as appropriate. You can download and print the form by clicking here or clicking the title of the form.

Notice of Privacy Practices
Would you like to know how we handle your private information? This form contains all of our standard practices for handling your personal, private and medical information as well as legally required practices. You can download and print the form by clicking here or clicking the title of the form.

Financial Policy
This document outlines our policies on billing insurance and timing on costs that are due for treatment and services. You can download and print the form by clicking here or clicking the title of the form.

 
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