New Patient Packet

areasontosmile.com (845) 457-5763

New Patient Packet

Step 1 — Patient Information

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender

Female Male

SSN

Only required if designated by your insurance co

Street address *

Apt #

City *

State *

Zip *

Home phone

Work phone

Cell phone *

Email *

Are you a new patient?

Yes No

Financial Information

Insurance Plan

Employer

Plan holder (if other than self)

Plan holder date of birth

SS/ID #

Relationship to patient

Aesthetics

Are you happy with the appearance of your teeth?

Yes No

Would you like your teeth to look whiter?

Yes No

Would you like to see your smile look different?

Yes No

Do you like the shape of your teeth?

Yes No

Are you happy with the appearance of your lips?

Yes No

Do you have discolored teeth that bother you?

Yes No

Are you here for a specific reason?

Yes No

If yes, please explain

Step 1 — Patient Information

Financial Information

Crop the card

Card

Aesthetics