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Patient Account Information
Please fill out all these forms before your first visit:




First Name
Last Name
Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email
Date of Birth
" size="30" onfocus="if(this.value=='mm/dd/yyyy'){ this.value=''; }"/> 		Name of Spouse/Partner
Closest Relative
Phone
Employer
Occupation
Business Address (include floor number)
City
State
Zip
Person Financially Responsible for Account
Phone (if different from self)
Address (if different from self)
City
State
Zip



Dental treatment is an excellent investment in an individual's medical and psychological well being. Financial considerations should not be an obstacle to obtaining this important health service. Being sensitive to the fact that people have different needs in fulfilling their financial obligations, we provide many payment options, including interest free monthly payment plans. If you have dental insurance, a completed dental claim form must be on file with this office. It is also your responsibility to notify us of any changes.

I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his staff, responsible for any errors or omissions that I may have made in the completion of this form.

Click to certify.

If you have any problems or questions regarding these forms, please call our office at 212.838.2900. We will be glad to assist you.







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Michael Krochak DMD and Joshua Perlman DMD do business as Manhattan Midtown Dental.
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