• Lindi J. Ezekowitz, D.D.S.
  • Rosalyn M. Sulyanto, D.M.D., MS

7 Graf Road
Suite 2A
Newburyport, MA 01950

(978) 462-2227

Patient Forms

Patient Forms (COVID Form)

The link below will open in a new window and will say “New Patient” at the top. This is the form we are using for everyone to update all COVID information, and we know who is a patient of record and who is a new patient.
Patient Registration Forms


HIPAA Privacy Notice

Consent Forms

Informed Consent for Patients

Caregiver Consent Form

Unaccompanied Minor Consent Form

Social Media Photo Consent Form