Lily W. Eng DDS

101 Lafayette Street, 9th Floor, New York, NY 10013

212-842-5300, 212-842-8042

Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible care. To help us meet all your dental needs, please fill out this form. If you have any questions or need assistance, please ask us – we will be happy to help.

Witness Initial:

PATIENT INFORMATION

Patient Name:
Birth Date:
Social Security#:
Home Phone:
Cell Phone:
Work Phone:
Ext
E-mail:
Best Way To Contact You:
Best Time to Contact You (Day & Time):
Available Appointment Time (Day & Time):
Address:
Apt:
City:
State:
Zip Code:
Gender:
Check Appropriate Box:
Name of Emergency Contact Person:
Phone # of Emergency Contact Person:
Relationship to Patient:
If Patient is a Student, Name of School / College:
Who / What Referred You Here:

RESPONSIBLE PARTY

Name of Person Responsible for this Account:
Birth Date:
Relationship to Patient
Is the Responsible Party Currently a Patient in our Office?
Address:
Apt:
City:
State:
Zip Code:

Responsible Person Signature:

Use your mouse cursor or the tip of your finger to sign below

Date:

I acknowledge that I am responsible for everything on this account, including financial balance.

INSURANCE INFORMATION (If you already gave us the insurance information, no need to fill out).

Primary Dental Insurance
Name of Insurance Company:
SS# or Member ID#:
Group #:
Name of Insured:
Birth Date of Insured:
Relationship to Patient
Address of Ins:
City:
State:
Zip Code:
Secondary Dental Insurance
Name of Insurance Company:
SS# or Member ID#:
Group #:
Name of Insured:
Birth Date of Insured:
Relationship to Patient
Address of Ins:
City:
State:
Zip Code:

PATIENT DENTAL HISTORY

Date of Last Dental Visit:
Do Your gums bleed while brushing or flossing?
Are your teeth sensitive to hot / cold liquids / food?
Are your teeth sensitive to sweet / sour liquids / food?
Do you feel pain in any of your teeth?
Do you have any sores or lumps in or near your mouth?
Have you had any head, neck or jaw injuries?
Have you ever experienced any of the following problems in your jaw?
a). Clicking?
b). Pain (joint, ear, side of face)?
c). Difficulty in opening or closing?
d). Difficulty in chewing?
Have you ever had instructions on the care of your gums?
Reason for this visit:
Do you have frequent headaches?
Do you clench or grind your teeth?
Do you bite your lips or cheeks frequently?
Have you ever had any difficult extractions in the past?
Have you ever had braces?
Have you ever had instruction on the correct method of brushing your teeth?

*What cosmetic concerns do you have that you would like to have corrected?

MEDICAL HISTORY

Are you allergic to or have you had any reactions to the following? Please check those that apply:
Doctor Initial:
Local Anesthesia (e.g. Lidocaine):
Penicillin:
Sulfa Drugs:
Barbiturates:
Sedatives:
Iodine:
Aspirin:
Codeine:
Latex:
Other (please list):

Women Only:

Are you pregnant or think you may be pregnant?
Are you nursing?
Are you taking birth control pills?
Have you ever had any of the following? Please check those that apply:
Type
Type
Please list medications you are currently taking
1. Name:
Dosage:
2. Name:
Dosage:
3. Name:
Dosage:
4. Name:
Dosage:
5. Name:
Dosage:
6. Name:
Dosage:
7. Name:
Dosage:
8. Name:
Dosage:
9. Name:
Dosage:
10. Name:
Dosage:

SLEEP HISTORY

Do you snore or have been told you snore?
Have you been told you stop breathing or gasp during sleep?
Do you feel groggy or unrefreshed in the morning?
Are you often fatigued during your day?
Do you fall asleep sitting, reading, watching TV or driving?
Have you been told that you grind your teeth during sleep?
Have you ever had a sleep study?
Do you have Obstructive Sleep Apnea or suspect you have OSA?
Are you currently being treated for OSA or another sleep disorder?
Have you ever had any complications following dental treatment?
If yes, please explain:
Are you now under the care of a physician?
If yes, please explain:
Name of Physician:
Phone:
Have you ever had any surgeries?
If yes, please list the surgeries and the date they were performed:
Have you been admitted to a hospital or needed emergency care during the past two years?
If yes, please explain:
Do you have any health problems that need further clarification?
If yes, please explain:

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctor(s) at the next appointment without failure.

Patient's Signature:

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Date:

Doctor's Signature:

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Date: