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415 Northern Blvd., Great Neck, NY 11021

516-858-5921

Enter your location for customized directions

Directions

Enter your location for customized directions

Directions

Enter your location for customized directions

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Treating you like family for over 44 years

516-858-5921

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Electronic Patient Forms

Step 1 of 3

33%

Name

First

Middle

Last
Email
Contact Preference
- Call
- Text
- Email
Preferred Name
Sex
- Male
- Female
Birthday
Age
Social Security Number
Address

Street Address

Address Line 2

City

State

ZIP Code
Marital Status
- Single
- Married
- Divorced
- Widowed
Home Phone
Cell Phone
Work Phone
Best place and time to contact you?
Referred By
Other family members seen by us
Present / Previous Dentist
Date of Last Dental Visit
Person Responsible for Account
Name

First

Last
Work Phone
Ext.
Home Phone
Address

Street Address

Address Line 2

City

State

ZIP Code
Relation to patient
Date of Birth
Spouse Section
Name

First

Last
Date of Birth
Phone
In the event of an emergency, is there someone who lives near you we should contact?
- Yes
- No
His/Her Name
Relationship to Patient
Work Phone
Home Phone
Dental History
Why have you come to the dentist today?
Do you require antibiotics before dental treatment?
- Yes
- No
Have you ever had a serious/difficult problem associated with any previous dental work?
- Yes
- No
Are you currently in pain?
- Yes
- No
I have a fear of / I have a concern about
- Experiencing Pain
- Needles
- Gagging
- Being Embarassed
- Losing my teeth/False Teeth
To understand what is going on in my mouth, my preference is :
- To know all the details
- To be given the bottom line
- To read pamphlets
- To talk with a team member about solutions to my problems
Do you now have or have you ever experienced pain/discomfort in your jaw? (TMJ/TMD)
- Yes
- No
Your current dental health
- Good
- Fair
- Poor
How many times a week do you floss?
Do your gums ever bleed?
- Yes
- No
Types of bristles
- Hard
- Medium
- Soft
Are you happy with your smile?
- Yes
- No

Primary Insurance Information
Primary Insurance Company Name
Primary Insurance Street Address

Street Address

Address Line 2

City

State

ZIP Code
Primary Insurance Company Phone
Primary Insurance Group Number
Insured’s First Name

Insured’s Last Name
Relation to Patient
Insured's Birthday
Insured's Social Security Number
Insured's Employer
Patient's Birthday
School Name if Attending:
Do you have secondary Dental Insurance
- Yes
- No
Secondary Insurance Information
Secondary Insurance Company Name
Secondary Insurance Company Address

Street Address

Address Line 2

City

State

ZIP Code
Secondary Insurance Group Number
Secondary Insurance Insured Name

Secondary Insured First Name

Last Name
Relation to Patient
Insured's Birthday
Insured's Social Security Number
Employer Name

Patient Medical History
Patient Name

First

Last
Address

Street Address

Address Line 2

City

State

ZIP Code
Date of Last Visit
Date of Medical History
Email
Home Phone
Work Phone
Birthday
Social Security Number
Marital Status
- Single
- Married
- Divorced
- Widowed
Primary Dental Guarantor
Home Phone
Work Phone
Secondary Dental Guarantor
Home Phone
Work Phone
Physician Name
Physician Phone
Pharmacy Name
Pharmacy Phone
Medical Alerts
Patient Gender
- Female
- Male
Are you taking birth control pills?
- Yes
- No
Are you pregnant?
- Yes
- No
Are you nursing?
- Yes
- No
Do you smoke or use tobacco?
- Yes
- No
BP

Heart Rate
Height
Weight
Existing Medical Conditions
- Abnormal Bleeding
- Alcohol Abuse
- Allergies
- Anemia
- Angina Pectoris
- Arthritis
- Artificial Bones
- Artificial Heart Valve
- Asthma
- Blood Transfusion
- Cancer- Chemotherapy
- Colitis
- Congenital Heart Defect
- Cosmetic Surgery
- Diabetes
- Difficulty Breathing
- Drug Abuse
- Emphysema
- Epilepsy
- Fainting Spells
- Fever Blisters
- Frequent Headaches
- Glaucoma
- Hay Fever
- Heart Attack
- Heart Surgery
- Hemophilia
- Hepatitis A
- Hepatitis B
- High Blood Pressure
- HIV + AIDS
- Kidney Problems
- Liver Disease
- Low Blood Pressure
- Mitral Valve Prolapse
- Pace Maker
- Pneumocystitis
- Psychiatric Problems
- Radiation Therapy
- Rheumatic Fever
- Seizures
- Shingles
- Sickle Cell Disease
- Sinus problems
- Stroke
- Thyroid Problems
- Tuberculosis
- Ulcers
- Venereal Disease
- Yellow Jaundice
Allergies
- Aspirin
- Codeine
- Dental Anesthetics
- Erythomycin
- Jewelry
- Latex
- Metals
- Penicillin
- Tetracycline
Allergies – Other/not listed above
Please list your medications
Is there any disease, condition, or problem that you think this office should know about that is not covered above?
- Yes
- No
If Yes, Please provide any information you feel is relavant.
Policies

Your Appointment is reserved and requires 48 hour notice of cancellation. We reserve the right to charge a fee of $50 for every 1/2 hour of missed appointment for this time

You Agree that we may release information to the insurance carrier regarding your records.

Payment is due when services are rendered.

All past due accounts of more than 30 days are subject to a 1.5% monthly finance charge.

MY SIGNATURE BELOW INDICATES THAT I HAVE READ THIS ENTIRE FORM. PROVIDED CORRECT INFORMATION, AGREE TO THE CONDITIONS LISTED ABOVE AND THAT I UNDERSTAND THAT FILING INSURANCE CLAIMS IS MY RESPONSIBILTY

It will be signed at office visit.
Patient's Signature (if minor, Parent/ Guardian must sign)
Date
I DR. Passes, Have Reviewed the Medical History
Doctor's Signature
Date

Location Info & Directions

415 Northern Blvd., Great Neck, NY 11021

516-858-5921

Monday (Alternate): 7:00 AM – 4:00 PM
Tuesday and Wednesday: 10:00 AM – 7:00 PM
Thursday: 9:00 AM – 6:00 PM
Friday: 7:00 AM – 4:00 PM
Saturday (Alternate): 8:00 AM – 2:00 PM
Sunday: 9:00 AM – 2:00 PM

About Passes Dental Care

We welcome patients of all ages and invite you to explore our website and learn more about Passes Dental Care. Whether you’re experiencing tooth pain or want to improve the beauty of your smile with Invisalign, our doctors create customized care plans for each smile. We are conveniently located in Great Neck, NY and proudly service patients from Manhasset, Roslyn, Little Neck and surrounding communities.

Connect with Passes Dental Care

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Passes Dental Care

415 Northern Blvd Great Neck NY 11021

COVID-19 UPDATE

WE REMAIN OPEN AS AN ESSENTIAL SERVICE FOR OUR PATIENTS WHO ARE EXPERIENCING BOTH DENTAL EMERGENCIES AND PRE-EMERGENCY SITUATIONS. OUR PRACTICE BELIEVES THAT WE HAVE A MORAL & ETHICAL OBLIGATION TO OUR PATIENTS AND OTHERS IN THE COMMUNITY WHO MAY BE IN NEED OF EMERGENCY DENTAL CARE.

SHOULD YOU HAVE AN EMERGENCY, GIVE US A CALL AT 516-402-1396.