Andrew Tomash, DDS, FRCD(C)

Certified Specialist in Pediatric Dentistry
And Associates​


NEW PATIENT REGISTRATION

THE FOLLOWING INFORMATION IS NECESSARY AND WILL BE KEPT STRICTLY CONFIDENTIAL
 

Patient's Name:

 
 
 
 


Patient's Birth Date:

 
 
 

Gender:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

FINANCIAL ARRANGEMENTS 

THE POLICY OF THIS OFFICE IS: PAYMENT AS EACH DAYS TREATMENT IS COMPLETE 
 
 
 
 
 
 
 
 
 
 
 

Secondary insurance coverage (if applicable): 
 
 
 
 
 


I authorize release to Dr’s Yale Y. Rao / Dr. Andrew Tomash information contained in pre-authorizations and claims submitted electronically and otherwise.  I also authorize release of information pertaining to my dental coverage and benefits. 
 

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HEALTH HISTORY 

 
 
 
1.  Are you in good health?    
 
 
 
 3. 
 4. 
 
  5. Have you ever been advised to take antibiotic pre-medication prior to dental treatment?    

6. Do you have allergies?
 
 
 
 
 
7. Are you presently taking any kind of medication?  If yes please specify:
 
 
 
 9. Please indicate below if you presently have or have ever had any of the following:
 
 
 
 

PATIENT DENTAL HISTORY 

 
 
 
 
 
 
 
 

Please indicate Yes (Y) or No (N) to the following:
 
 
 
 
 
 
 
 
 
 
 

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