• Fingeret Dental, Family & Cosmetic Dentistry

    Registration & Health History Form
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  • Sex
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Marital Status
  • Student:
  • Format: (000) 000-0000.
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  • Work status
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Rows
  • If you selected Yes for Hepatitis, Hepatitis Type
  • Have you been hospitalized in the last five years?
  • Do you take an aspirin on a daily basis?
  • Are you under a physician's care presently?
  • Have you ever been a drug or substance abuser?
  • Do you smoke?

  • I attest that I understand and answered all the above questions honestly and completely, I understand that the doctor is basing his treatment on this information. | authorize the release of information to Insurance carriers and other health care professionals who are involved in my care. I assign my insurance benefits to Andrew I. Fingeret D.M.D. unless otherwise indicated.

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  • Your signature Indicates you have read the HIPAA law as well as releasing Dr. Fingeret to utilize any dental photographs at his discretion.

  • Cancellations and Financial Responsibility

    Appointments are held exclusively for you. You are required to give "day before" notice of cancellation of an appointment. You can notify us by calling the office or sending an email. Failure to give "day before" notice will incur an office charge of $75. Emergency cancellations are assessed case by case.

    I agree to be responsible for all office fees and applicable co-pays at the time of service. In addition if I have dental insurance and my claim is denied for any reason, including exhausting of benefits or failure to meet a deductible, I will be responsible for payment of unpaid services.

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