212-697-1701       121 East 60th Street Suite 1B  New York, NY  10022
Welcome To Smiles Park Avenue Dental New Patient Information
  1. smileslogo

    121 East 60th Street Suite 1B    New York, NY 10022     Tel: (212)697-1701  Fax: (212)755-2747  www.smilesparkavenuedental.com

  2. First Name(*)
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  3. Last Name(*)
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  4. Middle Initial
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  5. Address(*)
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  6. City(*)
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  7. State(*)
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  8. Zip Code(*)
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  9. Home Phone(*)
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  10. Work Phone
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  11. Cell Phone
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  12. E-mail(*)
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  13. Company Name
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  14. Company Address
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  15. Occupation
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  16. Marital Status(*)
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  17. Date of Birth(*)
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  18. Age(*)
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  19. Preferred appointment day(*)
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  20. Contact information and emergency contact.
  21. How should we contact you?
  22. Referred By
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  23. Emergency Contact
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  24. Contact Telephone
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  25. Please answer all the questions.
  26. Date of last dental exam(*)
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  27. Date of last series of complete mouth x-rays(*)
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  28. Are you in good health?
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  29. Has there been any change in your general health within the past five years?
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  30. Do your gums bleed when you brush?
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  31. Are you happy with your Smile?
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  32. Do you smoke cigarettes, cigars, or pipes?
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  33. Are you interested in whitening your teeth?
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  34. Do you have any problem eating certain foods?
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  35. Do you have sensitivity to hot or cold foods?
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  36. Have you ever been Pre-Medicated with antibiotics before any dental treatment ?
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  37. Have you had orthodontics?
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  38. If yes, how many years_______at what age________?
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  39. List ALL hospitalizations and serious illnesses, including dates.
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  40. Do you have or ever had any of the following?





























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  41. Do you have any allergies? (*)
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  42. If yes what?
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  43. Have you ever taken penicillin?(*)
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  44. Have you ever had a bad reaction to any drug or medication?





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  45. List other medications you are allergic to?
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  46. [WOMENT ONLY] Are You Pregnant?
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  47. Are you under the care of a physician?(*)
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  48. List all of the drugs or medications you are taking now.
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    Provide name, how long, dosage, and reason.
  49. Please provide the name of your primary care physician.
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  50. Physician Address(*)
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  51. In addition to those you have listed, have you taken any of the following medications or drugs within the past year? If yes please check the appropriate box.
  52. Additional Medications















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  53. Signed this date
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  54. Relationship to Patient
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  55. E-Signature(*)
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  56. Captcha (*)
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  57.   

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