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Patient Forms and Information

What to expect at your first appointment at our office.

  • Review medical and dental history
  • Take necessary digital x-rays
  • Dr. Roznik will do a thorough exam
  • Dr. Roznik, along with the patient, will determine a course of treatment based on patient's needs
To Save Time for You, please download, print and fill out the following forms and bring with you to your first visit with us. To View and Print the forms, you will need Adobe Acrobat Reader, download for FREE!

NEW patient forms, see below!

New Patient Registration Form

New Patient Office Financial Policy Form

New Patient General Procedures Agreement Form

Authorization for Release of Information

New Patient Privacy Practices Agreement Form

Acknowledgement of Receipt of Notice of Privacy Practices


Finance options:All Major Credit Cards and   dentist care credit


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If your previous dentist has digital x-rays, you may request that they be emailed to:

Most insurance is accepted and filed for you.

Occasionally treatment can be done the same day

Also check out our links page for more great dental information!


Uptown Premier Dental is located in the heart of Uptown Charlotte
400 South Tryon Street, Suite M4, Charlotte, NC 28285

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