Welcome to

Flushing Family Dentistry!

The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out this form completely. The better we communicate, the better we can care for you.

Personal Information

Spouse/Parent Information

Dental Insurance Information

PRIMARY

SECONDARY

Medical History Information

In case of emergency, is there someone nearby we can contact?

Medical History

For Women Only:

Are you allergic or have you reacted adversely to any of the following (check all that apply):

Please list all medications you are currently taking, including prescription drugs, over-the-counter drugs, vitamins, herbal remedies and supplements. (If you have a list, please present list)

Dental History