New Patient Questionnaire

“State of the art equipment; beautiful office”

“Visiting the office is like seeing my family. This office is extremely friendly and warm”

Suite 206, Miami, FL 33176
Ph: (305) 274-2110
Fax: (305) 274-2109
New Patient Questionnaire >>
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PATIENT INFORMATION:

Patient’s Name:

Address:

Phone #:

Cell #:

E-mail:

INSURANCE INFORMATION:

Name of Policy Holder:

Policy Holder’s SSN:

Policy Holder’s DOB:

Patient’s DOB:

Policy Holder’s Employer

Insurance Company:

Group #:

Insurance Ph. #:

What time and day will work best for you to come see us?

Are you having any discomfort, pain, or anything bothering you that we should be aware of?

Location and period of time you’ve been having discomfort/pain:

Is there anything about your dental health/smile that you would change or are unhappy with?

WHEN WAS YOUR LAST DENTAL CLEANING AND EXAM?

Have you ever been told you need to take antibiotics before dental treatment?

Are you allergic to any medication?

Pharmacy Name/Phone # (IF antibiotics necessary):