700 White Plains Rd, Ste 20, Scarsdale  |  (914) 713-2424  |  24/7 Emergency Care  |  Se habla español
New Patients

Patient Information

Complete your new patient forms online before your visit. It saves time at the office and lets your care team prepare for your appointment.

Before Your First Visit

New patients are asked to complete a health history, dental history, and consent forms. You can fill everything out below, or complete it at our office when you arrive. All information is kept confidential.

1

Complete the Form

Fill out your patient information, medical history, and dental history online.

2

Review & Acknowledge

Read and acknowledge the consent to treatment and privacy practices.

3

Arrive Relaxed

Your forms are ready, so your first visit can focus on you and your care.

New Patient Intake Form

Fields marked * are required. Estimated time: 8–10 minutes.

Preview only — secure online submission is not active yet. Please do not enter sensitive medical details for now. To share health information, call (914) 713-2424 or complete this form at your visit.
1Patient Information
2Medical History
Are you in good general health?
Has your health changed in the last year?
Hospitalized or serious illness in the last 5 years?
Are you currently under a physician's care?

Symptoms — check any you currently experience

Check all that apply.

Conditions — do you have, or have you had, any of these?

Check all that apply.

Do you use any of the following?

Have you been told to take antibiotics before dental treatment (pre-medicate)?
3Dental History

Have you experienced any of these?

Check all that apply.

Does dental treatment make you afraid or nervous?
Is the brightness of your teeth important to you?

If you could change anything about your smile, what would it be?

Check all that apply.

4Consent & Acknowledgments

Consent to Examination & Treatment

I authorize Scarsdale Dental Spa to take the necessary X-rays, study models, photographs, and other diagnostic records needed to evaluate my dental needs, and to provide the dental treatment, medication, and therapy determined to be appropriate. I understand that the use of anesthetic agents carries certain risks, which have been or will be explained to me.

Acknowledgment of Privacy Practices (HIPAA)

I acknowledge that I have been offered a copy of Scarsdale Dental Spa's Notice of Privacy Practices, which describes how my health information may be used and disclosed. I understand I may request a copy at any time. You may decline to acknowledge; declining will be noted for our records and will not affect your care.

Your information is confidential and is used only to prepare for your dental care. No payment or billing details are collected on this form.
This online form is a preview and is not active for submission yet. To share health information, please call (914) 713-2424 or complete this at your visit.
Prefer to complete your forms in person? You can fill them out when you arrive — please come 15 minutes early. Questions? Call (914) 713-2424.

Ready to Schedule?

Book Online Call (914) 713-2424