AMES, IA NEW PATIENTS – DR. NIEGSCH & DR. KROOK
Patient Forms

Save time during your first appointment by completing these forms online. This information is needed before your first appointment. All forms are submitted directly to our office through our secure site. If you have any questions while completing these forms, give us a call.

OUR EXISTING DENTAL FAMILY MEMBERS CALL OR TEXT (515) 268-0516

Dentistry At Somerset Patient Portal

New Patient Forms

If you have recent X-rays (within the past year) or other relevant information from your previous dentist that you would like us to have, please complete our Records Release Form.

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Records Release

In order to get files in time for your appointment, we’ll need this form at least one week in advance of your scheduled appointment.

I, hereby request and authorize

Address

To disclose and provide copies of any and all clinical treatment records and information concerning my care, which is in the possession of this person or entity, to:

Dentistry at Somerset, Jason Niegsch, DDS, FAGD

2720 Stange Road / Ames, IA 50010

Phone: (515) 268-0516 / Fax: (515) 268-9161

Preferred Method Email:
smile@DentistryAtSomerset.com

These records include, but are not limited to: personal patient information, medical and dental histories, examination records, radiographs, clinical photographs, treatment plans, treatment records, referral and consultation recommendations and reports, diagnostic models and other related materials. I expressly release from liability the above named person or entity from any and all liability arising from compliance with this request and disclosure of the requested information.

If transferring family, please use head-of-household name above and list other family members below:

AMES IOWA FAMILIES – MEMBERSHIP CLUB

No Dental Insurance?

Join our

Dentistry At Somerset Membership Club

and get your preventive care for a low monthly subscription fee.

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AMES IOWA FAMILIES – MEMBERSHIP CLUB

No Dental Insurance?

Join our

Dentistry At Somerset Membership Club

and get your preventive care for a low monthly subscription fee.

Need An Appointment?

Jason Niegsch, DMD, FAGD
Daniel Krook, DDS

Existing Patients: (515) 268-0516
New Patients: (515) 337-2244

Our Location

2720 Stange Road
Ames, IA 50010
Click for Map & Directions

Pay Online

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Office Hours

Mon
Tue
Wed
Thu
Fri
Sat
Sun

8:00am – 5:00pm
8:00am – 5:00pm
8:00am – 5:00pm
8:00am – 7:00pm
8:00am – 5:00pm
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