manhattanbestdental.com - New Patient Form

The following is for:

Employer Name:

Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Would you consider yourself to be in fairly good health?

Within the past year, have there been any changes in your general health?

What is the date (or approximate date) of your last medical exam?

Date

Your Primary Care Physician's name, address, & phone number:

Please mark any of the following to indicate Yes in response to the question:

If any of the previous questions are marked, please explain:

WOMEN ONLY: Are you pregnant?

If YES, when is the due date?

Date

Please indicate if you have experienced any of the following:

Do you have any other health issues or allergies?

What is the reason for your dental visit today?

When was your last visit to the dentist (if it a different office)?

What was done on your last dental visit (if to a different office)?

Prior Dentist's name, address, & phone number:

How frequently do you brush your teeth?

How frequently do you floss your teeth?

Please mark any of the following to indicate Yes in response to the question:

If any of the previous questions are marked, please explain:

If you could change anything about your mouth, teeth, or smile, what would it be

Authorization

I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge thatproviding incorrect and/or inaccurate information has the potential of being hazardous to my health. I authorize the diagnosis of my dental health by means ofradiographs, study models, photographs, or other diagnostic aids deemed appropriate. I authorize the dentist to release any information including the diagnosisand records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practitioners. I authorize thepayment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account. Iunderstand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for thisremaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any).

Patient Information

Spouse or Responsible Party Information

Employment Information

Medical and Dental Form

Consent for Services