New Patient Information Forms


	Patient Login

New Patients

Welcome.
We know you have a choice in your dental care and we want to thank you for taking the time to learn more about us. You can feel confident that we at the New York Center for Neuromuscular Dentistry will make you comfortable about your decision. Furthermore, we will work our hardest at keeping your teeth healthy and looking beautiful. Nobody cares more about your teeth than we do.

On or before your first appointment, we will need some general information about your dental and medical history. We offer two easy ways to do this. You can either fill out the form online or when you visit our office. Kindly come in 10 minutes prior to your appointment time in order to maintain efficient scheduling. Please note that we maintain the strictest standards in keeping all of your information confidential.

PATIENT INFORMATION


Title		Name


Street Address


City		State		Zip


Birthdate	Social Secuirty #	E-Mail

Home Phone #	Work Phone #	Cell Phone #

How shall we contact you regarding appointments? (Check all that apply)
	Home		Work		Cell		E-mail

Full-time student?
(Check, If applicable)

School Name
(If applicable)

Marital Status
	Minor	Single	Married
	Separated	Divorced	Widowed

Person to Contact in an Emergency

Whom may we thank for referring you to us?

EMPLOYMENT INFORMATION

Employer

Employer's Street Address


City		State		Zip


Occupation

INSURANCE INFORMATION


Insurance Company


Street Address


City		State		Zip

Phone Number of Insurance Company

Name of the Insured

Relationship to Patient
	Self		Spouse		Child		Other


Birthdate		Social Secuirty #

Insured's Employer
Group Number

Please note, we do not accept insurance for payment. Therefore, according to your insurance company, we would be considered an "Out of Network" doctor. However, we will be happy to provide you with an insurance form to submit. Please see insurance page for more information.

DENTAL HISTORY


Previous Dentist


Street Address


City		State		Zip

Phone Number of Previous Dentist

Do you give us permission to contact your previous dentist to obtain your recent x-rays?

Yes

Please check any of the following concerns that apply to you:
Teeth:
	Bad Breath	Loose Filling
	Broken/ Chipped	Missing Filling
	Crooked	Loose Tooth
	Decay	Missing Tooth/Teeth
	Difficulty Chewing	Mouth Sores
	Discolored	Sensitive to Hot Temperature
	Food Trap Areas	Sensitive to Cold Temperature
	Grinding/Clenching	Sensitive when Biting
	Tooth Pain
Gums:
	Bleeding	Bump
	Sore/Sensitive	Sore Mouth
Jaw/Facial:
	Facial Pain	Jaw Pain
	Frequent Headaches	Pain in Cheeks or Temples
	Jaw Clicks

How happy are you with your smile?
How concerned are you with your overall dental health?
Yes or No? Would you like a whiter, brighter smile?

Past Dental History:
Last Dental Visit (Approximate)
How often do you frequent the dentist?
	Months	Years	As Needed
Do you usually take antibiotics prior to dental treatment
	Yes	No	Unsure
If so, which medication

Do you have a tooth replacement such as:
	Dentures	Partials	Bridges	Implants
Are you satisfied with the tooth replacement?

MEDICAL HISTORY

List Any Allergies Click All That Apply
	Antibiotics	Local Anesthethics	Sedatives
	Aspirin	Metals	Sleeping Pills
	Codeine	Novocaine	Sulfa Drugs
	Iodine	Penicillin	Other (describe below)
	Latex	Plastic

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