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Margolian Dentistry
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Alternately, the form can be filled online below

Patient Contact Information

Mr Mrs Ms Miss Dr

Insurance information

Primary Insurance Company

Secondary Insurance Company (if applicable)

I, understand, certify that I (or my dependent) have insurance coverage and assign directly to Drs. Bishara - Margolian DPC all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize Drs. Bishara - Margolian to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

* All fees or balances not covered by your dental insurance policy will be payable at time of visit. You must provide us with all insurance information. We do not have access to your private insurance policy information unless provided to us.

Referral Information

How did you hear about us?

Website Internet Yellow Pages Referral

Dental History

Please check any of the following that may apply to you


Grinding or clenching teeth

Tooth Pain or Discomfort While Chewing

Bleeding, swollen or irritated gums

Headaches, earaches, or neck pain

Loose or shifting teeth

Jaw Joint Pain (clicking/cracking)

Bad breath or taste in the mouth

Broken Teeth or Fillings

nitrous oxide (laughing gas) oral medication

If you could change your smile, you would...

Make your teeth brighter/whiter Repair chipped teeth

Make your teeth straighter Replace missing teeth

Close spaces Replace crowns

Replace fillings Have a smile makeover


Medical History

Please check any of the following that may apply to you

AIDS Diabetes

High Blood Pressure Rheumatic Fever

Allergies Emphysema

HIV Positive Seizures

Anaemia Excessive Bleeding

Jaundice Snoring/Sleep Apnoea

Arthritis Fainting

Kidney Disease Stomach Problems

Artifical Joints Glaucoma

Liver Disease Stroke

Asthma Heart Conditions

Low Blood Pressure Thyroid Disease

Blood Disorders Heart Murmur

Pacemaker Tuberculosis

Cancer Heart Disease

Pregnant Ulcers

Chemotherapy Hepatitis A, B or C

Respiratory Problems Other

Do you have any allergies?

Aspirin Codeine Penicillin

Sulpha Drugs Local Aesthetic Latex


    I certify that I have read, understood and accurately completed the personal, medical and dental histories to the best of my knowledge and have not knowingly omitted any information. If required, I consent to my physician being contacted regarding any specific medical questions. I authorize Drs. Bishara - Margolian and their staff to perform necessary diagnostic procedures and treatment as required to achieve a proper level of dental care.


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We are looking forward to hearing from you.
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