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

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: