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📞 💬 718-808-9898

For New Patients

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Patient Forms

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Have Questions?

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Name *

Email *

Your Phone Number *

Phone

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Patient Forms

Please fill out the form below.

Date

First Name

Last Name

Gender

Male Female

Birthdate

Age

How did you hear about our office?

Name

Relationship

Are you the legal guardian?

Yes No

First Name

Last Name

Primary Phone

Address

First Name

Last Name

Primary Phone

Address (if different than mother's)

Insurance Company

Insured's Name

Insured's Social Security Number

Policy Number

Group Number

Insurance Phone Number

Is your child taking any medications?

Yes No

Is your child allergic to any medications?

Yes No

Does your child have a history of any major illness or serious medical condition?

Yes No

Has your child had any major operations?

Yes No

Does your child have any special needs or learning/developmental disabilities?

Yes No

Is your child allergic to LATEX?

Yes No

Is this your child's first visit to the dentist?

Yes No

Have there been any injuries to your child's face, mouth or teeth?

Yes No

If yes, please explain

I have checked that the above information is correct and accurate to the best of your knowledge.

718-808-9898
142-38 37th Avenue Suite 1F, NY 11354
info@example.com

About Us
Testimonials
Services
For New Patients
- New Patient Form (English)
- 新病人表格(中文)
Resources
Contact

About Us
Testimonials
Services
For New Patients
- New Patient Form (English)
- 新病人表格(中文)
Resources
Contact

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Best Pediatric Dentistry in NYC

Contact Info

718-808-9898
142-38 37th Avenue Suite 1F, NY 11354
info@shiningdental.com

Office Hours

Monday 10AM–5:30PM
Tuesday 10AM–5:30PM
Wednesday by appointment only
Thursday by appointment only
Friday 10AM–5:30PM
Saturday 10AM–5:30PM
Sunday Closed

About Us
Testimonials
Services
For New Patients
- New Patient Form (English)
- 新病人表格(中文)
Resources
Contact

About Us
Testimonials
Services
For New Patients
- New Patient Form (English)
- 新病人表格(中文)
Resources
Contact