359 Boylston Street, 6th floor (Penthouse)
Boston, Massachusetts 02116
Telephone (617) 262-1422
mail@bostonteeth.com

New Patient Information
Name:

Today's Date:

Address:

    Street:
    City:
    State: Zip Code:
Home Telephone:
Work Telephone:
Cell Phone:
Dental Insurance:
Group #:
Referred by Who:
Previous Dentist's Name
Telephone:
Chief Complaint. What concerns you the most?


Do you take Pre-Medication for dental visits? Ex. Valium or Amoxicillin:

Could you request the transfer of the following documents. Please check off.
Copies of records
All x-rays
Medical Clearance forms from Physician (to indicate for example if you require premedication because of the following conditions: Heart Disease, Anxiety, Contageous Diseases or Prosthetic Implants)

I will bring with me
Full Mouth X-Rays Series
Treatment Plans

How often do you receive cleanings (Hygiene Prescription/Rx)
6 months
4 months
3 months

I would like information in the following:
Image Consult.
Finance Consult.
Call Back

Appointment Dates, Days, and Times Preferred:


What length and type of appointment do you prefer?
Extended appointments of several hours (more treatment done but less frequent)
Shorter appointment (but more frequent)

Personal Notes: