New Patient Forms
NOTICE TO PATIENTS: We utilize air filters & the latest technology in sterilization. Our office team down to the cleaning crew have been vaccinated. Continuing from Thursday, May 13th, 2021, we continue to follow CDC / Hospital Protocol in our office. We are continuing our patient treatment protocols because of the coronavirus disease outbreak. Your appointment may be affected. If you currently feel sick, please reschedule and call your physician. The same thing applies if you have traveled outside the US recently or had exposure with anyone with a positive to the coronavirus testing or had any fever, cough, sneezing or shortness of breath in the last 48 hours. We are here for you and will be glad to see you during our shortened clinical hours Mon – Thurs.
Welcome to our office! We practice what we preach! We are different because when you choose dental care with us you have access to a network of comprehensive and specialty dental care practitioners who communicate together regularly for comprehensive, convenient, accessible dental health care supported by the latest technology and research, commitment to patient education and dental disease prevention, and personal dental care planning with comprehensive follow-up.
We accommodate patients appointments efficiently. The cost of dentistry in this office is competitive, and we will respect your financial needs as you often have treatment options. We submit through insurance on your behalf should you need this, please have your insurance information readily available. If you leave us a message we will respond within 24 hours and you will be seen for consult within 2 weeks of your request.
Notice of Privacy Practices Form
Other Links:
Periodontal Questionnaire and Exam
Orthodontic Questionnaire and Exam
Sleep Links:
Sleep Appliance Adjustment Follow-Up
TMD Links:
TMD Head, Neck Pain Exam and Workup
[PATIENT RIGHTS & RESPONSIBILITIES / HIPPA] (link under construction)
To Help Someone You Love Receive Dental Care:
Dr. Emerson offers Gift Cards!
Available in any amount. For an initial examination with diagnostic radiographs we recommend $150 – $300.
GIFT INFORMATION:
Gift Amount _____________________________
To _______________________________________
From ____________________________________
Gift Message ___________________________
DELIVERY METHOD:
► Pick up at North Seattle Restorative Dentistry
► Mail to Billing Address
► Mail to Recipient Address
PAYMENT METHOD:
Please contact our office for payment – 425-486-2715