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The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain optimal oral health. Please fill out this form completely. The better we communicate, the better we can care for you.

    • ABOUT YOU

    • SPOUSE INFORMATION

    • Payment is due in full at time of treatment. Unless prior arrangements have been approved
    • Relative or Friend not living with you (for emergency).
       
    • INSURANCE

    • PRIMARY INSURANCE

    • SECONDARY INSURANCE

    • If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all cost of dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my company.
    • (please print out and sign)
    • MEDICAL HISTORY (732) 458-5400

    • For Women:
    • Have you ever had any of the following diseases or medical problems?:
    • Are you allergic to any of the following:
    • OFFICE USE ONLY / MEDICAL HISTORY UPDATE

    • Has there been any change in your health status since your last visit?
    • DENTAL HISTORY

    • Are you happy with the way your smile looks:
    • I understand that the information that I have given is correct to the best of my knowledge, I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office an any changes in my medical status. I authorize the dental diagnosis and treatment, with my informed consent.
    • Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
    • OFFICE USE ONLY

    • I verbally reviewed/dental information with the patient herein.

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