Now Accepting New Patients! Click Here to Register.
Download Dental Registration – PDF Form
Thank you for choosing our office. We will strive to provide you with the best possible dental care.
To help us meet your entire dental healthcare needs, please fill out this form completely.
Patient’s Last Name
Preferred Name / Nickname
Social Security Number
How did you hear about our office?
FamilyFriend/CoworkerInsurance DirectoryInternet/EmailFlyer/Direct MailingOutdoor SignsMarketing Representative
Whom may we thank for referring you to your practice?
Other Family Members Seen Here
Person Responsible for Bill
Relationship to Patient (self/spouse/child)
Card Type: AmexVisaMaster CardDiscoverCareCreditLending ClubOther
Card Expiration Date
Subscriber’s Social Security #:
Subscriber’s Email Address:
Subscriber’s Street Address (if different from patient’s)
Subscriber’s Cell Phone
Subscriber’s Work Phone
Primary Insurance Company
Subscriber’s ID #:
Secondary Insurance Company
Reason for Today’s Visit:
Are you in pain?
If yes, how long?
Please indicate any of the following problems:
Red, swollen or bleeding gumsLost/broken filling(s)Blisters/sores in or around the mouthBroken/chipped toothStained teethSensitive to coldBad breathSensitive to heatRinging in earSensitive teeth or gumsTeeth grindingDiscomfort, clicking or popping in jaw
Do you require pre-medication (antibiotics prior to dental treatment)?
Last Dental Visit
Reasons for changing dentist:
MovedChanged insuranceNot satisfied with previous dentistReferred to our officeOther
Name of Primary Physician
Please indicate if you have or ever had any of the following diseases or medical conditions:
Heart Attack / StrokeStomach Problems / UlcersSevere/Frequent HeadachesHeart Surgery / PacemakerPsychiatric ProblemsFrequent Neck PainHeart MurmurVenereal DiseaseShinglesRheumatic FeverAlcohol / Drug AbuseAsthmaMitral Valve ProlapseTuberculosis (TB)Difficulty BreathingArtificial ValvesJaw Problems (TMJ / TMD)DiabetesHeart DiseaseCancer / TumorAnemiaCongenital Heart DefectChemotherapy / RadiationLow Blood PressureChest PainsHepatitisHigh Blood PressureScarlet FeverHIV+ / AIDSBleeding ProblemsKidney ProblemsArthritis / RheumatismGlaucomaLiver ProblemsArtificial Bones / JointsBack ProblemsRespiratory ProblemsEmphysemaSinus ProblemsFainting / Seizures / EpilepsyOther Medical Conditions
Please Describe Other Medical Conditions:
Please list all medications you are currently taking:
Are you allergic to any of the following?
AspirinPenicillinLocal AnestheticsIbuprofenCodeineSulfa DrugsLatexOther Medications
Please list any Other Medications, patient is allergic to:
Do you use tobacco?
If yes, what form?
Are you pregnant?
If yes, how long?
Are you nursing?
Name of Local Friend or Relative (not living at same address)
Relationship to Patient
Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with our Office Administrator, Carrell Clarke. We accept Cash, Checks, Master card, Visa card, American express card, and Discover card. We also offer financing through Carecredit and Lending Club.
I authorize and give consent to perform any necessary or advisable services during diagnosis and treatment.
I authorize consent for provider and staff to communicate with all physicians, hospitals, laboratories and insurance claims department pertaining to diagnosis and treatment on my behalf. I understand that I have the right to deny consent of release of my information at anytime.
We are “Out of Network” with all dental plans. If your dental insurance company allows for “Out of Network” coverage, we will file all dental claims and you will be responsible for paying the portion not covered by your dental insurance carrier. You are solely responsible for the full payment of all services not covered by your insurer and payment will be due at the time services are rendered. For all dental plans where “Assignments of Benefits” are issued to the subscribers we will expect payment of the full reimbursement amount plus your portion if any, no later than 48 hours after receipt. According to NYS Law we cannot write off any balances for services that were already paid for by your insurance carrier.
We must emphasize that, as dental care providers, our relationship is with you, not your insurance company therefore you are responsible for all charges from the date the services are rendered. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. If account is not paid within 90 days of the date of service 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.
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to Spyridon J. Condos, DDS, LLC. I understand that I am financially responsible for any balance.
Once your appointment is confirmed, please complete the Patient Screening Form.