New Patient Form -

Your Name*

First

Last

Please enter Parent’s Name if filling this form out on behalf or your child, or YOUR NAME if you are an adult, and the visit is for braces for yourself.
Home Address*

Street Address

Address Line 2

City

State

ZIP Code
Home Phone*
Cell Phone or Alternate phone #
Is this visit for:*
- Pediatric Dentistry with Dr. Rich Shulman
- Orthodontics (Braces) with Dr. Chris Miller
Is the orthodontic patient:*
- Your Child
- Yourself
Since Dr. Chris Miller provides orthodontic treatment for both children and adults, please let us know who is being seen.
Name of your dentist:*
Child's Name*

First

Last
Child's Date of Birth*

mm/dd/yyyy–
example, 02/25/1983
Name of your child's dentist*
Your Email

Will not be used by anyone other than our office

Do you have dental insurance?*
- yes
- no
If you answer “YES”, please be sure that you carry DENTAL insurance, and the information you provide is for your dental policy. Many families mistakenly provide us with their medical coverage information, assuming it is the same insurer/ policy number and it usually is not.
Dental Insurance Information
Insured Party*
Insured Party's Date of Birth*

mm/dd/yyyy– example: 02/25/1983
Insured Party's Employer*
Employer's Phone Number*
Employer's Address*
Dental Insurance Carrier*

The following information should be easily obtainable from your dental insurance card.
Insurance Carrier mailing address (from insurance card)*

Street Address

Address Line 2

City

State

ZIP Code
Insurance Company Phone Number*
Insurance ID number/ Social Security Number*

Please enter whichever is used by your insurance company for your ID, if unsure please enter both
Group Number*
Local Number

if applicable
Has your child (dependant) been added to your dental insurance*
- Yes
- No
Very important. Many families forget to do this, so if you have not, please check with the HR department at the place of your employment
Is your insurance a DHMO or HMO?*
- Yes
- No
We do not participate with any DHMO plans at this time. If you answered “YES”, please stop and call our office at 516-932-1101
Who can we thank for referring you to our office?
Name of referral souce*

New Patient Form