Dr. Goldfarb's New Patient Forms

Welcome to Our Practice
Please take a few minutes to answer the following questions so we can better assist you with your dental needs.
Today's Date

- Month - Day Year
Soc. Sec. #
Birthdate

- Month - Day Year
Name

First Name Last Name
Home Phone

Address

Business Address

Address

Business Address

Insurance Company Address

Address

Insurance Company Address

Subscriber I.D. #
Group #
Dental History
Former Dentist
City, State
Date of Last X-ray
How often do you floss?
Date of Last Dental Visit
How often do you brush?
Please check all that apply
Medical History
Physician's Name
Date of Last Visit
Are you currently under medical treatment?

Yes No
Have you ever had any serious illnesses or operations?

Yes No
Are you currently taking any medication?

Yes No
Do you smoke?

Yes No
Do you use alcohol, cocaine or drugs?

Yes No
Do you wear contact lenses?

Yes No
Have you had any allergic reactions to the following:

Local Anesthetics (e.g. novocaine) Penicillin or other Antibiotics Sulfa Drugs Barbiturates (sleeping pills) Sedatives Iodine Aspirin
(Women Only) Are you:

Pregnant? Nursing? Taking birth control pills?
Please check all that apply
Assignment and Payment
I hereby authorize payment directly for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents.

I authorize the above doctor and/or any provider or supplier of services in this office to release the information required to secure the payment benefits. I authorize the use of this signature on all insurance submissions.
Signature of Responsible Party *

Clear
Date *

- Month - Day Year
Should be Empty:

Welcome to Our Practice