Elizabeth Doroski, DDSFamily Dentistry · Riverhead Call (631) 727-0770
Patient forms

New patient forms

Welcome! New patients need two forms. Please bring both to your first visit.

1. Patient Intake Form

Your contact details, insurance and health history. Fill it out online below, then download or print it, sign it in ink and bring it with you. You can also download a blank copy to print.

Fill out online Download blank form (PDF)

2. Patient Consent Form

Download, print and sign this form in ink. We need your original signature, so please bring the signed paper copy with you.

Download consent form (PDF)

Online form

Patient Intake Form

Please fill out as much as you can. Fields marked * are needed, along with a home or cell phone number. Answer what applies to you and leave the rest blank.

Your answers stay on your device. Nothing is sent over the internet.

Patient Information (Confidential)

Optional. You may provide this at the office.
Patient's Sex
Do you prefer to receive calls at your:
Check Appropriate Box:
Student status

Responsible Party

Optional. You may provide this at the office.
Is this person currently a patient in our office?
For your convenience, we offer the following methods of payment. Please check the option you prefer. Payment in full at each appointment.

Insurance Information

Optional. You may provide this at the office.
Do you have any additional insurance?

Additional insurance (if yes, complete the following)

Optional. You may provide this at the office.

Patient Medical History

1. Are you under medical treatment now?
2. Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?
3. Are you taking any medication(s) including non-prescription medicine?
4. Have you ever taken Fen-Phen/Redux?
5. Have you ever taken Fosamax, Boniva, Actonel or any cancer medications containing bisphosphonates?
6. Have you taken Viagra, Revatio, Cialis or Levitra in the last 24 hours?
7. Do you use tobacco?
8. Do you use controlled substances?

9. Do you have or have you had any of the following?

High Blood Pressure
Heart Attack
Rheumatic Fever
Swollen Ankles
Fainting / Seizures
Asthma
Low Blood Pressure
Epilepsy / Convulsions
Leukemia
Diabetes
Kidney Diseases
AIDS or HIV Infection
Thyroid Problem
Heart Disease
Cardiac Pacemaker
Heart Murmur
Angina
Frequently Tired
Anemia
Emphysema
Cancer
Arthritis
Joint Replacement or Implant
Hepatitis / Jaundice
Sexually Transmitted Disease
Stomach Troubles / Ulcers
Chest Pains
Easily Winded
Stroke
Hay Fever / Allergies
Tuberculosis
Radiation Therapy
Glaucoma
Recent Weight Loss
Liver Disease
Heart Trouble
Respiratory Problems
Mitral Valve Prolapse
10. Are you wearing contact lenses?

11. Are you allergic to or have you had any reactions to the following?

Local Anesthetics (e.g. Novocain)
Penicillin or any other Antibiotics
Sulfa Drugs
Barbiturates
Sedatives
Iodine
Aspirin
Any Metals (e.g. nickel, mercury, etc.)
Latex Rubber
12. Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?

13. Women Only:

a) Are you pregnant or think you may be pregnant?
b) Are you nursing?
c) Are you taking oral contraceptives?

Patient Dental History

1. Do your gums bleed while brushing or flossing?
2. Are your teeth sensitive to hot or cold liquids/foods?
3. Are your teeth sensitive to sweet or sour liquids/foods?
4. Do you feel pain to any of your teeth?
5. Do you have any sores or lumps in or near your mouth?
6. Have you had any head, neck or jaw injuries?

7. Have you ever experienced any of the following problems in your jaw?

Clicking
Pain (joint, ear, side of face)
Difficulty in opening or closing
Difficulty in chewing
8. Do you have frequent headaches?
9. Do you clench or grind your teeth?
10. Do you bite your lips or cheeks frequently?
11. Have you ever had any difficult extractions in the past?
12. Have you ever had any prolonged bleeding following extractions?
13. Have you had any orthodontic treatment?
14. Do you wear dentures or partials?
15. Have you ever received oral hygiene instructions regarding the care of your teeth and gums?
16. Do you like your smile?

Authorization and Release

Payment is due in full at the time of treatment unless prior arrangements have been approved. This office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered to my insurance company. 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 confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent.

After you download or print your form, sign and date it below in ink.

X
Signature of patient (or parent/guardian if minor)
Date

All done? Download or print your form

Save your completed form as a PDF or print it. Then sign and date it in ink and bring it to your first visit along with your signed Patient Consent Form.

Call (631) 727-0770