Creating Gorgeous Smiles

New Patients Form

Great teeth, great smile, great life

- Step 1 of 11

Patient information

Welcome to our office. We appreciate the confidence you place in us to provide dental services. To assist us in serving you, please complete the following form. The information provided in this form is important to your dental health. If there have been any changes in your health, please tell us. If you have any questions, don’t hesitate to ask.

Name *

First

Last

Date of Birth *

Sex *

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Billing Address(if different)

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone *

Email *

Drivers License *

Social Security *

Employer/occupation

Business Phone

Spouse's Name

First

Last

Spouse's Phone

Emergency Phone (other than spouse) *

Primary Dental Insurance *

ID Number *

Secondary Dental Insurance

ID Number

Subscriber's Name *

First

Last

Date of Birth *

Social Security *

Name of Your Medical Doctor

Date of Last Visit to Medical Doctor

Name of Previous Dentist

Date of Last Visit to Dentist

Referred to us By

Dental Health History

Are you apprehensive about dental treatment? *

Have you had problems with previous dental treatment? *

Do you gag easily? *

Do you wear dentures? *

Does food catch between your teeth? *

Do you have difficulty chewing your food? *

Do you chew on only one side of your mouth? *

Do you avoid brushing any part of your mouth because of pain? *

Do your gums bleed easily? *

Do your gums bleed when you floss? *

Do your gums feel swollen or tender? *

Have you ever noticed slow-healing sores in or about your mouth? *

Are your teeth sensitive? *

Do you feel twinges of pain when your teeth come in contact with (check all that apply) *

Do you take fluoride supplements? *

Are you dissatisfied with the appearance of your teeth? *

How often do you brush your teeth? *

How often do you floss? *

Does your jaw make noise so that it bothers you or others? *

Do you clench or grind your jaws frequently? *

Do your jaws ever feel tired? *

Does your jaw get stuck so that you can’t open freely? *

Does it hurt when you chew or open wide to take a bite? *

Do you have earaches or pain in front of the ears? *

Do you have any jaw symptoms or headaches upon awaking in the morning? *

Does jaw pain or discomfort affect your appetite, sleep, daily routine, or other activities? *

Do you find jaw pain or discomfort extremely frustrating or depressing? *

Do you take medications or pills for pain or discomfort (pain relievers, muscle relaxants, antidepressants)? *

Do you have a temporomandibular (jaw) disorder (TMD)? *

Do you have pain in the face, cheeks, jaws, joints, throat, or temples? *

Are you unable to open your mouth as far as you want? *

Are you aware of an uncomfortable bite? *

Have you had a blow to the jaw (trauma)? *

Are you a habitual gum chewer or pipe smoker? *

Medical History

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

Heart Problems (Check all that apply) *

Chest Pain
Shortness of breath
Blood Pressure problems
Heart murmur
Heart valve problem
Taking heart medications
Rheumatic fever
Pacemaker
Artificial heart valve
None of the above

Blood Problems (Check all that apply) *

Easy bruising
Frequent Nosebleeds
Abnormal bleeding
Blood disease (anemia)
Ever require a blood transfusion?
None of the above

Allergies (check all that apply) *

Hay fever
Sinus problems
Skin Rashes
Taking allergy medication
Asthma
None of the above

Intestinal Problems (check all that apply) *

Ulcers
Weight loss or gain
Special Diet
Constipation/diarrhea
Kidney or Bladder problems
None of the above

Bone or Joint Problems (check all that apply) *

Arthritis
Back or neck pain
Joint replacement (hip, pins, implants, etc)
Fainting spells, seizures, epilepsy
Stroke(s)
Frequent or severe headaches
Thyroid problems
Persistent cough or swollen glands
Premedication required by physician
Cancer/tumor
None of the above

Diabetes *

Urinate more than 6 times a day
Thirsty or mouth is dry much of the time
Family history of diabetes
Tuberculosis or other respiratory disease
None of the above

do you drink alcohol? *

do you smoke? *

Hepatitis, jaundice, or liver trouble *

Herpes or other STD *

HIV - positive/AIDS *

Glaucoma *

History of head injury *

Epilepsy or other neurological disease *

History of alcohol or drug abuse *

Do you have any disease, condition, or problem not listed previously that you feel we should know about?

Are you allergic, or have you reached adversely to any of the following *

Local Anesthetics (Novocaine)
Penicillin or other antibiotics
Sulfa drugs
Barbiturates, sedatives, or sleeping Pills
Codeine, demerol, or other narcotics
Reaction to metals
Latex or rubber Dam
Other
None of the above

If other please describe

During the past 12 months, have you taken any of following (copy) *

Antibiotics or sulfa drugs
Anticoagulants(e,g., Coumadin)
High blood pressure medicine
Tranquilizers
Aspirin
Digitalis or drugs for heart trouble
Nitroglycerin
Cortisone (steroids)
Natural remedies
Others
None of the above

If other please describe

Woman, have you taken any of following *

Contraceptives or other hormones
Nursing
Reached menopause
None of the above

If so do you have any symptoms?

Add Note

Date / Time *

Financial Obligation for Patients Without Dental Coverage

I am not covered by any dental insurance and understand that I am responsible for payment in full at the time of service. I understand that by signing below, I agree to the above statement concerning my financial obligation with Rania Scander DMD, PA.

Patient's Name *

First

Last

Financial Obligation for Patients With Dental Coverage

I am providing my dental insurance information to Rania Scander DMD, PA. so that they may bill my dental insurance company (as a courtesy to me) for their services. I understand that I am responsible for charges to my insurance company until those charges have been paid in full. I also understand and agree with the following. 1. Rania Scander DMD, PA. will submit a bill for their services to my insurance company based on the information that I have provided. 2. Rania Scander DMD, PA. will provide my insurance company with the information that it needs for my claim(s) to be processed promptly. 3. I am responsible for verifying that Dr. Rania Scander is recognized as a covered provider by my insurance company before services are rendered. I understand that I will be responsible for any penalties imposed by my insurance company if Dr. Rania Scander is not on my insurance plan.

Please remember that your dental insurance is not designed to pay the entire cost of your treatment, but it is intended to help cover a certain portion of the cost. A better term for dental insurance may be “dental assistance.” The Financial obligation for your dental treatment is between you and this office, and is not between the insurance company and us.

I am responsible for and I agree to pay all co-pays, co-insurance and deductibles that are not covered by my insurance. I understand that my estimate may be inaccurate if dental work has been done in another dental office. I understand that any legal fees incurred by this office in collection of my balance, will be my responsibility. I understand that I am financially responsible for charges that have been denied by my insurance company immediately upon the first denial of those charges by my insurance company regardless of the reason the claim(s) is/are denied. I understand that by signing below, I agree to the above statements in order to ensure timely processing and payment of my bill with Rania Scander DMD, PA. I further understand that a copy of this statement will be provided to me upon my request.

Patient's Name *

First

Last

Hippa Authorization

I understand that my private health information may be used to refer to another Dental Office or medical facility, Pharmacy or my insurance company.

I give my permission for this office to discuss my medical/dental/financial information with the following person(s).

Patient's Name *

First

Last

Confirmation Permission

Our office does like to confirm your appointment prior to the scheduled appointment. We may occasionally need to leave a message on your answering machine or leave a message with a family member for you to call our office.

It is okay for the office to leave messages at my home? *

It is okay for the office to text you at your cell phone? *

If we are not able to leave a message at your home, is there another number you would like for us to call or text?

Appointments and Cancellations

When we make your appointment, we are reserving a room for your particular needs. We ask that if you must change an appointment, please give us at least 24 hours' notice. This courtesy makes it possible to give your reserved room to another patient who would like it.

There is a $65.00 charge for not showing up for scheduled appointments. Repeated cancellations or missed appointments will result in loss of future appointment privileges.

We feel that our patient's time is valuable. When your appointment is made, a room is reserved, your records are prepared, and special instruments are readied for your visit. Except for emergency treatment for another patient, you can expect us to be prompt. We, of course, would appreciate the same courtesy from you.

Patient's Name *

First

Last

Date *

Family Smiles & Implant Center

From cosmetic dentistry to full-mouth rehabilitation, our practice is equipped to handle all of your dental needs.

We accept most major insurances. We process claims on behalf of our patients. This saves them time and upfront costs. All major credit cards are accepted as well as Care Credit.

Serving all your family dental needs in Woodcliff Lake, Montvale, Park Ridge, Hillsdale, Westwood, Paramus, Mahwah, and more areas | Accepting new patients.

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Contact Us

Address: Perillo Tour Plaza
577 Chestnut Ridge Rd,
Woodcliff Lake, NJ, 07677

Office: (201)746-9500

Text: (201)614-7676

Email: [email protected]

Our office hours are:
Mon-Fri: 10:00 AM – 8:00 PM
Sat: 9:00 AM – 3:00 PM

Office Visits

Address: directions from Google Maps!