Northview Family Dentistry

A dental practice of Nichole Lubberts DDS

2700 5 Mile Rd. NE Suite 202
Grand Rapids, MI 49525
616.364.8769 (p)
Mon - Wed: 8 to 5pm
Thursday: 7 to 4pm
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Adult Registration

  • Patient Information

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  • Health History

  • Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

  • Patient Information continued...

  • Please enter a number from 18 to 110.
  • Responsible Party (if someone other than the patient)

  • Primary Insurance Information

  • Secondary Insurance Information

  • To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.

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Northview Dentistry Logo
2700 5 Mile Rd. NE Suite 202
Grand Rapids, MI 49525
616.364.8769 (p)
616.364.7884 (f)
Mon - Wed: 8 to 5pm
Thursday: 7 to 4pm
northviewfamilydentistry@gmail.com
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Meet the Doctor
Our Team
New Patient Forms
Insurance & financing
Contact us
American Dental Association member
Invisalign
Carecredit
Top 10 dentistry clinics in Grand Rapids, MI 2015
Congratulations to Northview Family Dentistry on winning the 2015 Patients' Choice Awards for Dentistry in Grand Rapids, MI DLN Volunteer

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