New Patient Request Form

Please complete the form if you would like to become a new patient at Northern Dental Access Center.

We review new patient submissions monthly to fill a limited number of available openings. Our practice primarily serves patients with state-funded insurance plans, including Medicaid. We also accept new patients with private commercial dental insurance on a limited basis.

Please be patient as we work through submissions. Submitting this form does not guarantee acceptance as a new patient or an appointment.

All fields are required so we have the information needed to create your patient account.

Phone inquiries about becoming a new patient will be directed to this form. If a disability or physical limitation prevents you from completing the form online, please call our office for assistance.

Thank you for your patience and interest in our practice!