New Patient Enrollment Form

  • Patient Update Form

    Ridgefield Dental Arts
  • Format: (000) 000-0000.
  • Date of Birth:
     - -
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Date of Birth:
     - -
  • Format: (000) 000-0000.
  • Date of Birth:
     - -
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Dental History

  • Format: (000) 000-0000.
  • Date of Last Dental Care:
     - -
  • Date of Last Dental X-rays:
     - -
  • Check if you have had problems with any of the following:

  • Medical History

  • Have you ever used bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva
  • Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).
  • Have you had any serious illnesses or operations?
  • Have you ever had a blood transfusion?
  • (WOMEN) Are you
  • Check if you have or have had any of the following:

  • AUTHORIZATION AND RELEASE

  • I certify that I, and/or my dependent(s) have dental insurance coverage with the above mentioned dental company and assign directly to Bilius Family Dentistry DBA Ridgefield Dental Arts all insurance benefits, if any, otherwise payable to me for services rendered.  I understand that I am financially responsible for all charges whether or not paid by insurance.  I authorize the use of my signature on all insurance submissions.

     The above-named dentist/dental office may use my health care inforamtion and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.  

     I fully understand that I am required to give 24 hours advanced notice if I need to cancel or reschedule a dental appointment.  Failure to do so will result in a non-refundable $50 cancellation fee charge.

  • Date*
     - -
  • Should be Empty: