Medical history form2018-08-23T18:21:33+00:00

Patient Forms

Medical history form

Please download and print the following two documents. Bring the signed forms to your first appointment.

Also complete the medical history form below, and it will be sent directly to us.

  • Patient Medical History

  • Women Only

  • Patient Dental History

  • Do you have or have you had any of the following?

  • Have you ever experienced any of the following problems in your jaw?

  • Sleep Screening Questionnaire

  • Epworth Sleepiness Scale
    How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired?

    0= I would never doze
    1= I have a slight chance of dozing
    2= I have a moderate chance of dozing
    3= I have a high change of dozing
  • Authorization and Release

  • Payment is due in full at the time of treatment unless prior arrangements have been approved. This office accepts insurance. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I herby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I herby authorize release of any information, including the diagnosis and records of treatment or examination rendered to my insurance company. I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest, confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent.

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908-200-7007

1484 NJ-31
Annandale, NJ
08801

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