Washington Square Dental Group, P.C.
Mark D. Horowitz, D.D.S. ● Kori L. Darling, D.D.S.●ANNE X. TRUONG, D.D.S.
Two Fifth Avenue, Suite 4 – New York, N.Y. 10011
Tel: 212-674-4011 / Email:
Web:
Patient Information
Patient Name:______Gender: ______Date: ______
Date of Birth:______SSN: ______
Check One:_____ Married ______Single ______Divorced ______Widowed
Address:______Street Apt. #
______
CityStateZip
Whom can we thank for referring you to our practice? ______
Contact Information
Cell: ______Home:______Work: ______Ext: ______
Email:______
Emergency Contact
Name:______Phone: ______Relationship: ______
Employment Information
Employer Name: ______Occupation:______
Employer Address: ______Phone Number:______
Insurance Information
Dental Insurance: ______
Subscriber Name: ______Subscriber DOB: ______
Subscriber Address: ______
Subscriber SSN:______Relationship to Patient:______
ID Number:______Group Number:______
General Health History
PLEASE PRINT NAME: ______
please check any that apply
Washington Square Dental Group, P.C.
Mark D. Horowitz, D.D.S.
Kori L. Darling, D.D.S.
Anne X. Truong, D.D.S.
Two Fifth Avenue, Suite 4 – New York, N.Y. 10011
Tel: 212-674-4011 / Email:
Anemia
Heart Condition
Pacemaker
Thyroid
High Blood Pressure
Low Blood Pressure
Diabetes
Liver Problems
Kidney Failure
Fainting Spells
Anxiety / Mental Illness
Gallbladder
Cancer History
Chemotherapy
Radiation
Bleeding Issues
Blood Disease
Blood Transfusions
Asthma
Mitral Valve Prolapse
AIDS/HIV
Jaw Pain
Rheumatic Fever
Artificial Heart Valve
Glaucoma
Stroke History
Tobacco (Smoker)
Circulatory Problems
Hepatitis
Tuberculosis
Ulcers
Epilepsy
Headaches / Migraines
Washington Square Dental Group, P.C.
Mark D. Horowitz, D.D.S.
Kori L. Darling, D.D.S.
Anne X. Truong, D.D.S.
Two Fifth Avenue, Suite 4 – New York, N.Y. 10011
Tel: 212-674-4011 / Email:
Daily Medications/Recent Surgeries?/Joint Replacement?: ______
Allergies?:______
Dental History
Previous Dentist: ______Phone: ______
Address: ______
Most Recent Exam: ______Cleanings: ______X-Rays: ______
What are your immediate dental concerns? ______
Are you happy with the appearance of your smile? Circle One: Yes /No
Would you like to discuss enhancing the appearance of your smile? Circle One: Yes /No
Would you like to discuss options for teeth whitening? Circle One: Yes /No
Have you undergone prior orthodontic treatment? Circle One: Yes /No
Check if you have had problems with any of the following:
Washington Square Dental Group, P.C.
Mark D. Horowitz, D.D.S.
Kori L. Darling, D.D.S.
Anne X. Truong, D.D.S.
Two Fifth Avenue, Suite 4 – New York, N.Y. 10011
Tel: 212-674-4011 / Email:
Bad Breath
Bleeding Gums
Clicking/Popping Jaw
Food Collection
Grinding Teeth
Loose Teeth
Broken Fillings
Periodontal Tx
Sensitivity to Hot/Cold/Sweets
Mouth Sores/Growth
Washington Square Dental Group, P.C.
Dr. Kenneth Berger Dr. Mark Horowitz Dr. Kori Darling
2 Fifth Avenue, Suite 4 – New York, N.Y. 10011
Tel: 212-674-4011 / Email: / Web:
CONSENT
The above information is accurate and complete to the best of my knowledge. The undersigned hereby authorizes the Doctor to perform all the necessary procedures deemed appropriate for my dental needs.
Patient Signature (Guardian, if Minor)Date
Dentist SignatureDate
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