Patient Account Information

Please make certain to fill out all five forms before you come for your first visit so that we can spend your entire first visit diagnosing your dental condition and mutually establish the trusting, caring relationship we value having with all our patients.

  1. Medical History Form
  2. Patient Account Information
  3. Corah's Dental Anxiety Scale
  4. Mount Sinai Dental Fear Inventory
  5. No Show & Cancellation Policy

Name *
Name
Address
Address
Home Phone *
Home Phone
Work Phone
Work Phone
Cell Phone
Cell Phone
Preferred Method of Contact *
Select one or up to three.
Date of Birth *
Date of Birth
Please enter their name and number below.
How did you hear about us? *
Telephone
Telephone
Business Address
Business Address
Telephone (if different from self)
Telephone (if different from self)
Address (if different from self)
Address (if different from self)
A note about treatment.
Dental treatment is an excellent investment in an individual's medical and psychological well being. Financial considerations should not be an obstacle to obtaining this important health service. Being sensitive to the fact that people have different needs in fulfilling their financial obligations, we provide many payment options, including interest free monthly payment plans. If you have dental insurance, a completed dental claim form must be on file with this office. It is also your responsibility to notify us of any changes.
Checkbox *
I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his staff, responsible for any errors or omissions that I may have made in the completion of this form.