Patient Forms

‚ÄčHealth History (print, fill out and bring in)

HIPPA Consent (print, fill out and bring in)

Notice of Privacy Practices (print and keep)

Office Policy (print and keep)

Prior to or at your first appointment you will be asked to complete a brief health and dental history form for us. 


Financial information:

We are a participating PPO provider with Guardian, Aetna, Cigna, Ameritas, Delta Dental, POMCO, and Daniel H. Cook. Please bring your most recent insurance card with you and review your plan so you are aware of any deductible/co-insurance due. Payment is required at the time service is provided. We accept cash, check, and all major credit cards. We also participate with CareCredit. 

If we do not participate with your insurance we can still work with you! Just make sure your plan allows for out of network visits. We will happily fill out an insurance reimbursement form on your behalf so that you will be reimbursed directly from your insurance company. In certain cases a payment plan can be provided to you and we will gladly provide pre-estimates as needed as well.

Please Note: We do not participate with any form of Medicaid, Medicare, or HMO insurance.

If you are a Medicaid user you must see a Medicaid provider. If you have an HMO dental plan you must see the dentist that is assigned to you. If you are utilizing Medicare benefits you may be able to see an out of network provider and be reimbursed directly from your insurance, call your insurance provider for more information.  

29 Fox St, Ste. 301

Poughkeepsie, NY 12601

Daniel J. Gasperini, DDS

(845) 471-2311