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Health History

Address

How did you hear about us? Please check below.

Responsible Party Information
If patient is under 18, responsible party must complete this section.

Dental Insurance Information

If you have dual coverage, please provide information on your secondary insurance below.

Dental History

Medical History

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.

Please check any of the following that you have had or currently have:

Women

By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

Looking forward to giving you the
smile that lights up the room!
Looking forward to giving you the smile that lights up the room!
Contact us, or schedule
an appointment
Email Us
Call Us Today
718-882-7202
Call Us Today
718-882-7202