If you need a more accessible version of this website, click this button on the right.Switch to Accessible Site

Dental | Patient Forms and Information in South Bend

University_Park_Logo_Final_CMYK.jpg

University Park Family Dentistry
Jeffrey A. Turner, DDS

16597 State Road 23

South Bend, IN  46635

574.272.4441

Patient Forms and Information
 

Welcome to

University Park Family Dentistry, LLC

Dr. Jeffrey Turner


  • Photo Identification
  • Insurance Card (Dental and Medical) with booklet (if you have one)
  • Complete New Patient Forms by clicking on New Patient Forms, complete and submit
  • Previous dental records (if < 1 year since last dental visit)
  • Co-pay
  • List of current medications
  • A SMILE! J  

 

NEW PATIENTS:  If you can not make your scheduled appointment,

please contact our office with at least 48 hours notice,

failure to do so may result in future appointments being on "walk-in" basis ONLY.

Click on the form(s) you need to complete:

 

New Patient Forms

Existing Patient Health History Update

HIPAA Release Form

Address and/or Insurance Update

HIPAA Policy

All Medicaid or HIP patients

All Medicare patients

 


 
 
 
South Bend Dentist | Patient Forms and Information. Jeffrey Turner, DDS is a South Bend Dentist.