New Patient Form

NY Dental PC

Chart # ____________________________________________________
FOR OFFICE USE ONLY

PATIENT INFORMATION:
Date:

Patient Name:

Last, First, MI (Preferred Name)
Gender:
             

Social Security #
Birth Date
Driver's License #

Phone (Home)
(Work)
(Cel)

(E-mail)

What is your preferred method of communication?
                        

Address
Apartment #

City
State
ZIP

Pharmacy phone
E-mail

I prefer to be addressed on correspondence as
in person

Spouse's Name
MARITAL STATUS:
                                    

Employer
Occupation

Bus. Phone

In case of Emergency, call
Cell

Phone
Address
(Name of close relative NOT living at your home address.)

Name

Phone
Address
Whom may we thank for referring you?

Name

Phone
Address

Did you visit our web site?   http://nycdental-dds.com
            


DENTAL INSURANCE INFORMATION
Do you have dental insurance?
            

If yes: Name of Primary Carrier

Address

Group Insurance No
ID #
Is your treatment accident related?
            

If yes: Date of Accident

Attorney handling the accident
(Name)
(phone number)

Do you have medical insurance?
            

If yes: Name of Primary Carrier

Address

Group Insurance No
ID #


Signature

Date:

274 Madison Ave, Suite 202, Manhattan, NY, 10116
Tel.: 718-645-7000 | E-mail: alldental92@yahoo.com
www.nycdental-dds.com
Do you have or have you ever had any of the following?

Y N Condition
Y N Condition

MEDICATIONS
Are you sensitive or allergic to any medications?

Penicillin
            
Sulfa Drugs
            

Tetracycline
            
Codeine
            

Have you ever had penicillin?
            

Do you have any tattoos or body piercing?
            
Location?

Does exposure to the sun cause you to break out?
            

Do you wear contact lenses?
            

Have you ever taken:
                 
Date:

Please list any additional medications and reason for use:
              

Medication:
Dosage/Number of years
Prescribing doctor
Reason for use
Medication:
Dosage/Number of years
Prescribing doctor
Reason for use
Medication:
Dosage/Number of years
Prescribing doctor
Reason for use


Signature

Date:

274 Madison Ave, Suite 202, Manhattan, NY, 10116
Tel.: 718-645-7000 | E-mail: alldental92@yahoo.com
www.nycdental-dds.com
DENTAL HISTORY

Have you ever had a local anesthetic? (Lidocaine, etc.)
            

Have you ever had an unfavorable reaction to a local anesthetic?
            

Have you had any serious trouble associated with any previous dental treatment?
            

When was your last x-ray?

When was your last dental treatment?

Does dental treatment make you nervous?
            

Have you ever had Nitrous Oxide Analgesia (gas) during dental treatment?
            

MEDICAL HISTORY

Personal Physician
Telephone

Do you have any Biomedical or tissue implants such as:


Date
Chin
Breast
Dental
Knee
Hip
Heart Valve
Craniofacial

Do you use tobacco?
            
                  

If so, how often?

Do you use alcohol?
            
If so, how much?

Do you use drugs?
            
If so, what type and how much?

Have you traveled abroad recently or experienced any health related symptoms after traveling abroad?
            

Have you spent any extended period of time in foreign countries?
            

Have you ever experienced diarrhea for extended periods of time? (2 to 3 months)
            

Have you ever been treated by any of the following?





Signature

Date:

274 Madison Ave, Suite 202, Manhattan, NY, 10116
Tel.: 718-645-7000 | E-mail: alldental92@yahoo.com
www.nycdental-dds.com

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