Stamford Cosmetic Dentist | Invisalign Dentist Stephen Wolpo Dental Office

General Dentist| Preventative Dentistry | Dental Implants | Crowns | Tooth Implants | Invisalign | Gum Disease

phone(203) 399-0707

Call Us Now- 24/7 Customer Support

Save

LocationOur Location

60 Strawberry Hill Ave, Suite L-2, Stamford CT 06902

Patient Intake

Downloadable PDF Version of This Form

Patient Intake Form

  • Date Format: MM slash DD slash YYYY

  • Personal Information

  • Responsible Party (if self, skip to the next section)

  • Secondary Responsible Party (if different from above):

  • Primary Dental Insurance Company

  • Secondary Dental Insurance Company

  • Dental Information

  • Medical History

  • Do you have or have had any of the following diseases, medical conditions or procedures? (Please check proper box.)

  • Are you currently or have you taken in the past (either orally or through IV) any of the following drugs:

  • For women only

  • Terms of Service

  • Our policy requires payment in full for all services rendered at the time of the visit, unless other arrangements have been made with our office. If the account is not paid in full of the date of services and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and any other expenses incurred in collecting your account. I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims. " I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided."