New Patient Form

Patient Registration

Insurance Information

Primary Dental Insurance Company

Secondary Dental Insurance Company

Health Information

Please fill out the following health history to the best of your knowledge. All patient information is confidential. Although endodontisis primarily treat the mouth area,medical problems or medication could have significant impact on your dental.

Are you under the care of physician?

Have you had any operation or been hospitalized in the past five years?

Are you required to take antibiotics before every dental visit?

Do you Smoke?

Women Only

Are you pregnant?

If pregnant,how many weeks?

Are you nursing?

Is there a possibility of pregnancy?

Please Note:Antibiotics (sush as penicillin)may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control.

Health History

Have you had or do you currently have any of the following(Please circle Y or N) .

High Blood Pressure

Low Blood Pressure

Damaged Heart valve / Heart Murmur / Mitral Valve Prolapse

Rheumatic Fever /Heart Diease (RHD)

Chest Pain/Angina

Heard attack

Irregular Heart Beat

Pacemaker /Implanted Defibrillator

Heart Surgery /Bypass Surgery

stroke / Trasient Ischemic Attack

Thyroid Problems

Low Blood Sugar

Diabetes (Type I OR Type II)

kidney Disease

Bronchitis/chronic cough


Hay fever/Sinus Problems


Emphysema /COPD

Difficulty Breathing / Lung Problems

Blood Transfusion


Bleeding Disorder

Jaundice /Liver Disease

Hepatitis (Which Type?)

Infectious Mononucleosis

Arthritis /Joint Disease

Stomach Ulcer/ Colitis

Infectious Disease

Sexually Transmitted Disease

AIDS or HIV Positive

Inmune System Problem

Tumor or Growth

Radiation or Chemotherapy /Cancer

Chronic Fatigue

Malignant Hyperthermia

Eye Disease / Glaucoma

Psychiatric Treatment

Clicking of the jaw TMJ

Convulsion / Epilepsy/ Fainting

History of drug Abuse

Eating Disordes


Please list all medicine,drugs,pills,herbal medicines and over-the-counter medications you are taking.

Are you currently taking or have you previously taken biophosphonate medications ,such as Actonel Fosamax.


Are you allergic to or have you had a reaction to any of the following:

Local Anesthetics
/Epinephrine .

Penicillin .

Others Antibiotics .

Aspirin .

Codeine or Others Narcotics .

Sulfa .

Latex .

Others .

Is there any additional health issue about which the doctor should be told

Financial Policy

Our office is committed to providing you with the best dental care possible. In order to achieve this goal, we need your assistance and understanding of our financial policy. In order to serve you better we have prepared several payments options; please initial which suits you best.

Self Pay - You are responsible for your fees at time of service. For your convenience we accept cash, personal check, Visa, MasterCard, Discover and American Express. Your balance must be paid in full.

Dental Insurance - Most dental plans do not cover all endodontic services in full. Your estimated out of pocket will be due on the day services are rendered. If you have any questions regarding your insurance or estimated co-pay, please ask prior to treatment.

Care Credit- This is a credit card. You have to apply before your appointment. IT MUST BE DONE PRIOR TO TREATMENT. You are responsible for your fees at time of service and your financial agreement is with Care Credit. We offer 6 months interest free. Please ask for further details.

I understand fully that I am responsible for my account at Microendodontics Specialty Center PL. and agree to pay according to the selection above.

CONSENT TO WIRELESS TELEPHONE CALLS: If at any time I provide a wireless telephone number at which I may be contacted, I consent to receive calls or text messages, including but not restricted to communications regarding billing and payment for services, unless I notify the office to the contrary in writing. In this section, calls and text messages include but not restricted to pre-recorded message, artificial voice messages, automatic telephone dialing devices or other computer assisted technology, or by electronic mail, text messaging or any other form of electronic communication from the office, affiliates, contractors, servicers, clinical providers, attorneys or its agents including collection agencies.

CONSENT TO EMAIL USAGE: If at any time I provide an email address at which I may be contacted, unless I notify the office to the contrary in writing, I consent to receiving discharge instructions, statements, bills, marketing material for new services and payment receipts at that email address from the office.

Payment is due upon services rendered.