Fill Out New Patient Forms

Print out form to Bring In or Fax

 
Patient's Name:
 
 
 
Date*
Address:
 
 
 
 
Mailing Address if Different:
 
 
 
 
Spouse's Name:
 
 
 
Mailing Address if Different:
INSURANCE:
 
 
 

Physician:
 
 
 

Subscriber S.S. #:
 
Secondary Insurance:
Policy #:
Group #:
 
 

Medicines:
Allergies:
Check any of the Following:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Check any of the Following:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
How often do you brush?
How often do your Floss?
Last Dental Appointment
Dentist Name:
 
 
Chief Complaint (Reason for Today's Visit):
What do you like most about your smile?
Is there anything you would like to change about your smile?
What do you expect from your dentist and staff?
What did you like most or least about previous dentist?
How did you find out about our office?
 
 
 
I hereby authorize Dr. Ross Epstein and his staff to take X-rays, study models, photographs and all other necessary diagnostic aids required to formulate and perform a complete and comprehensive treatment plan. I also agree to comply with the doctor's decision on a systematic order of treatment accoring to the priority system of standard care. I also give my permission to Dr. Epstein and his staff, in the course of treatment, to consult any and all persons necessary to complete my dental care in a timely and responsible manner. I also agree to a 1.5% monthly interest rate on all delinquent accounts over 30 days, except where previous arrangements have been made. I understand that insurance is not a guarantee of payment and I am responsible for all fees not covered by insurance. I take full responsibility for all late payments made after 60 days by insurance companies. In the event of a divorce or separation, I agree to complete the payments for all outstanding bills that remail. I am also responsible for all fees charged by collection agencies and lawyers in pursuit of delinquent accounts. I understand that a minimal fee applies to all failed or cancelled appointments without 24 hours prior notice. All the above information is true and I understand and agree to all of the above policies as set forth by Dr. Ross Epstein.
Patient or Guardian: