212-697-1701       121 East 60th Street Suite 1B  New York, NY  10022
New Patient Information Form
  1. First Name(*)
    Please type your full name.
  2. Last Name(*)
    Please type your full name.
  3. Middle Initial
    Please type your full name.
  4. Address(*)
    Please enter your address.
  5. City(*)
    Please enter your city.
  6. State(*)
    Please enter your state.
  7. Zip Code(*)
    Please enter your zip code
  8. Home Phone(*)
    Please enter your home phone number.
  9. Work Phone
    Please enter your work phone number.
  10. Cell Phone
    Please enter your cell phone number.
  11. E-mail(*)
    Invalid email address.
  12. Company Name
    Please enter your company name.
  13. Company Address
    Please enter your company address.
  14. Occupation
    Please enter job title.
  15. Marital Status(*)
    Please tell us how big is your company.
  16. Date of Birth(*)
    Please enter your date of birth.
  17. Age(*)
    Invalid Input
  18. Preferred appointment day(*)
    Please select a date when we should contact you.
  19. Contact information
  20. How should we contact you?
  21. Referred By
    Invalid Input
  22. Emergency Contact
    Invalid Input
  23. Contact Telephone
    Invalid Input
  24. Answer all Questions
  25. Date of last dental exam(*)
    Invalid Input
  26. Date of last mouth x-rays(*)
    Invalid Input
  27. Are you in good health?
    Invalid Input
  28. Has there been any change in your general health within the past five years?
    Invalid Input
  29. Do your gums bleed when you brush?
    Invalid Input
  30. Are you happy with your Smile?
    Invalid Input
  31. Do you smoke cigarettes, cigars, or pipes?
    Invalid Input
  32. Are you interested in whitening your teeth?
    Invalid Input
  33. Do you have any problem eating certain foods?
    Invalid Input
  34. Do you have sensitivity to hot or cold foods?
    Invalid Input
  35. Have you ever been Pre-Medicated with antibiotics before any dental treatment ?
    Invalid Input
  36. Have you had orthodontics?
    Invalid Input
  37. If yes, how many years_______at what age________?
    Invalid Input
  38. List ALL hospitalizations and serious illnesses, including dates.
    Invalid Input
  39. Do you have or ever had any of the following?





























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





    Invalid Input
  44. List other medications you are allergic to?
    Invalid Input
  45. [WOMENT ONLY] Are You Pregnant?
    Invalid Input
  46. Are you under the care of a physician?(*)
    Invalid Input
  47. List all of the drugs or medications you are taking now.
    Invalid Input
    Provide name, how long, dosage, and reason.
  48. Name of your primary care physician.
    Invalid Input
  49. Physician Address(*)
    Please enter your address.
  50. 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.
  51. Additional Medications















    Invalid Input
  52. Signed this date
    Please type your full name.
  53. Relationship to Patient
    Invalid Input
  54. E-Signature(*)
    Please enter your name.
  55.