New Patient Registration/Medical History

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Patient Information

Parent/Guardian Information (Child Only)

Spouse/Emergency Contact

Insurance Information

Miscellaneous Information

To make sure we address all your concerns -- and answer any questions you may have – please take a minute to mark the areas of you dental care that you would like to discuss with Dr. Siegel and/or Dr. Dolt:

Medical History

Although dental personnel primarily treat the area in and around the mouth, your mouthy is a part of your body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Authorization

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 of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.