ADVT
New Patients Form - Dr. Robert P. Rothenberg

New Patients Form

Patient’s Information ( Confentials )


Responsible Party

Payment in full is expected at each appointment.
Insurance Information


OVER PLEASE


9. Are you allergic to or have you had any reactions to the following?
10. Women Only:
8. If you have now, or have had any of the following, please circle.
Patient Dental History

7.Have you ever experienced any of the following problems in your jaw?
I certify that I have read and understand the above information. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to my child or me during the period of such dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand and agree that if charges are not paid when due, interest will be charged on the overdue balance at the rate of one and one-half (1 ½ ) percent per month, and if dentist undertakes any collection action, I will be responsible for costs of collection, including reasonable attorney’s fees.