• New Patient Forms

  •  - -
    Pick a Date
  •  - -
    Pick a Date
  • In Order To Serve You Properly, We Need The Following Information. All Information Is Strictly Confidential. Please Print Clearly. 

  • I understand that I am financially responsible for all charges for services to me. Including the balance remaining after payment of possible insurance benefits

  • Clear
  •  - -
    Pick a Date
  • I authorize the release of any medical information necessary to process this claim.

  • Clear
  •  - -
    Pick a Date
  • Please answer all questions by marking yes or no. Your response to this questionnaire will be held strictly confidential and will only be used to assist in the assessment of your medical condition. If you have any hesitations, please discuss your concern with one of the faculty members.

  • Do you have or have you  had any of the following:

  • Cardiovascular Disorders

  • Respiratory Disorders

  • Musculo -Skeletal / CNS / Develop Mental Disorders

  • Gastrointestinal / Genitourinary Disorders

  • Hematologic / Endocrine / Immune Disorders

  • Psychiatric

  • Family History (Grandparents, Parents, Sisters, Brothers, Children

  • Allergies

  • Females

  • Clear
  •  - -
    Pick a Date
  • Patient’s Acknowledgement of Receipt of Dental Materials Fact Sheet

  • I, {patientsName} , acknowledge I have received from Dr. Shoffet-Yaghoubian a copy of the Dental Materials Fact sheet dated October 2001. 

  • Clear
  •  - -
    Pick a Date
  • Acknowledgement of Receipt of Notice of Privacy Practices

  • You May Refuse to Sign This Acknowledgement

  • I, , have received a copy of the Notice of Privacy Practices.

  • Clear
  •  - -
    Pick a Date
  • If this acknowledgement is signed by a personal representative on behalf of the patient, complete the following

  • Clear
  •  - -
    Pick a Date
  • Should be Empty: