Patient Forms & Financing

Call us today to set up an appointment 402-932-0282 or login to our patient portal!

Patient Forms

Help us to better know your needs.

Register or sign into our patient portal to fill out patient forms, check statements, update your info and more:



Or if you prefer, download and print this form to help us get to know you and your dental needs better:

Welcome New Patient Form

Sleep Apnea Patients:

TMD Patients:

  • TMD Questionnaire

We appreciate the time and attention you are giving us. This information is helpful in the process that we have to welcome you into our practice and serve your healthcare needs as best we can. If you have any questions about any of the information on the forms or the forms themselves, please do not hesitate to contact our office today.

Discrimination disclosure – Dentistry for Health Complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, origin, age, disability, or sex.

Languages we can take reasonable steps to support to provide free-of-charge assistance in providing dental care.


Smile Now, Pay Later!

Our Dental Clinic has partnered with three types of Health Care payment options in order to make financing easier on you. With CareCredit, Springstone and DOCPAY ACH, you can smile now and pay later!

These three options are briefly summarized below with links to their websites for more information.

1459206_origCareCredit is a credit card that can be used for treatments and procedures done in Dentistry, Cosmetic Treatments, Vision Care, Veterinary, Cosmetic Surgery, Hearing Care and more. It can be used for your entire family. With many of CareCredit’s payment options, interest can be avoided by making your minimum monthly payments and paying off the full amount due by the end of the promotional period. If the promotional purchase is not paid in full within the promotional period or if you make a late payment, interest will be charged to your account from the purchase date forward. Minimum monthly payments are required.

CareCredit allows you to get the dental care and treatment you need today. CareCredit can be used over and over without reapplying for you and your family. An application can be submitted for you at our office, or you can apply online or call (800) 677-0718. The application is quick and easy, and after it’s submitted, you’ll instantly learn if you’re approved. To learn more, you can visit the CareCredit website.

lending-club-logo2Lending Club makes patient financing easy and affordable. High approval rates, an easy online process, and no hidden fees – Lending Club just makes sense.

Contact or call our office at (402) 932-0282 with any questions you may have about your financing options.