Patient Forms

Forms

Select a form – Fill out and check your form before submitting.
Need help or have questions? Contact us at (607) 748-4151

New Patient Information

Step 1 of 7

14%

Financially Responsible Party
May not be same as patient
Name
Last First
Nick Name Middle
Address
Street Address Address Line 2 City State ZIP Code
Phone (Home)
Phone (Work)
Phone (Cell)
Sex
- Male
- Female
Marital Status
- Single
- Married
- Separated
- Divorced
- Widowed
Birth date

Employee Information
Employer
Employer's Address
Street Address Address Line 2 City State ZIP Code
Employer's Phone Number

Dental Insurance Company
Dental Insurance Company
Dental Insurance Company's Address
Street Address Address Line 2 City State ZIP Code
Dental Insurance's Phone Number
Group Number

Patient
Name
Last First
Nickname Middle
Address
Street Address Address Line 2 City State ZIP Code
Phone(Home)
Phone(Work)
Phone(Cell)
Sex
- Male
- Female
Marital Status
- Single
- Married
- Separated
- Divorced
- Widowed
Birth date
Social Security #
Primary Insurance
Secondary Insurance

Spouse
Name
Last First
Birth date
Social Security #
Check all that apply
- Patient
- Policy Holder
- Responsible Party

Spouse - Employment
Employer
Employer's Address
Street Address Address Line 2 City State ZIP Code
Contact
Employer's Phone Number

Spouse - Insurance Company
Insurance Company
Insurance Company Address
Street Address Address Line 2 City State ZIP Code
Insurance Company Phone Number
Group Number

In case of emergency

Name
This field is for validation purposes and should be left unchanged.

New Patient Survey

Thank you for helping us serve you and our future patients better by taking a few moments to complete this survey

New Patient Name*
First Last
Date*
Age:*
Sex:*
- Male
- Female
Occupation*
If you were referred, who referred you?
What was said to you that interested you in trying out our office?
If you responded to an advertisement, which one?
What about the advertisement initially attracted your attention?
Once your attention was attracted to the ad, what about the ad interested you enough to read it?
If you responded to our website, how did you locate it?
What about the website interested you?
What do you hope our office will be like?
How can we exceed your expectations?
Email
This field is for validation purposes and should be left unchanged.

Acknowledgement of Receipt of Notice of Privacy Practices

Giordano DentaI/Southern Tier TMJ & Sleep Therapy 864 Hooper Road Endwell, NY 13760
View the Notice of Privacy Practices Here
I have received a copy of this office's Notice of Privacy Practices.
Name:*
First Last
Date*
For Office Use Only
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:
- Individual Refused to Sign
- Communication barriers prohibited obtaining the acknowledgement
- An emergency situation prevented us from obtaining acknowledgement
- Other (Please specify)
If other, please specify here:
Electronic Signature (E-Signature) Agreement
By selecting the "I Accept" button, you are signing this Release of Records electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Release of Records. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You also represent that you are authorized to sign this Release of Records for all persons listed on this form.*
- I Accept
Electronic Signature:
Name*
First Last
Today's Date*
Name
This field is for validation purposes and should be left unchanged.

Sleep Release of Records

View the Notice of Privacy Practices Here
Release of Records
I authorize the office of (insert in box below) to release copies of records including, but not limited to: report of PSG sleep study along with dictation, any follow-up titration studies and dictations, x-rays, pertinent chart notes, prescription for oral sleep appliance, and other related information. I also authorize the above named office to send digital copies of these records via their office email address to Dr. Giordano's office email: info@giordanodental.com.*
If by mail, send to: Dr. Loius M. Giordano 864 Hooper Road Endwell, NY 13760 607-748-4151 (phone) 607-484-0061 (fax)
This record release is for:
Requesting records from (Office):*
Name:*
First Last
Date of Birth*
Name:
First Last
Date of Birth
Name:
First Last
Date of Birth
Name:
First Last
Date of Birth
Electronic Signature (E-Signature) Agreement
By selecting the "I Accept" button, you are signing this Release of Records electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Release of Records. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You also represent that you are authorized to sign this Release of Records for all persons listed on this form.*
- I Accept
Electronic Signature:
Name*
First Last
Today's Date*
Name
This field is for validation purposes and should be left unchanged.

Release of Records

View the Notice of Privacy Practices Here
Release of Records
I authorize the office of (insert in box below) to release copies of records including, but not limited to: X-rays (PAN, bitewings, full-mouth, etc.), copies of chart (patient history), and other related information. I also authorize the above named office to send digital copies of these records via their office email address to Dr. Giordano's office email: info@giordanodental.com.*
If by mail, send to: Dr. Louis M. Giordano 864 Hooper Road Endwell, NY 13760 607-748-4151 (phone) 607-484-0061 (fax)
This record release is for:
Requesting records from (Office):*
Name:*
First Last
Date of Birth*
Name:
First Last
Date of Birth
Name:
First Last
Date of Birth
Name:
First Last
Date of Birth
Electronic Signature (E-Signature) Agreement:
By selecting the "I Accept" button, you are signing this Release of Records electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Release of Records. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You also represent that you are authorized to sign this Release of Records for all persons listed on this form.*
- I Accept
Electronic Signature:
Name*
First Last
Today's Date*
Name
This field is for validation purposes and should be left unchanged.

Schedule an Appointment Today!

If you are suffering from any of the above symptoms please contact us today
to schedule an appointment with our TMJ and Sleep Therapy Specialists!

Contact Us

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864 Hooper Road Endwell , NY 13760

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(607) 748-4151

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Patient Forms

Forms

New Patient Information

Step 1 of 7

Financially Responsible Party

Employee Information

Dental Insurance Company

Patient

Spouse

Spouse - Employment

Spouse - Insurance Company

New Patient Survey

Authorization to Share Information

Patient Information

Electronic Signature (E-Signature) Agreement

Electronic Signature:

Acknowledgement of Receipt of Notice of Privacy Practices

Giordano DentaI/Southern Tier TMJ & Sleep Therapy 864 Hooper Road Endwell, NY 13760

I have received a copy of this office's Notice of Privacy Practices.

For Office Use Only

Electronic Signature (E-Signature) Agreement

Electronic Signature:

Sleep Release of Records

Release of Records

This record release is for:

Electronic Signature (E-Signature) Agreement

Electronic Signature:

Release of Records

Release of Records

This record release is for:

Electronic Signature (E-Signature) Agreement:

Electronic Signature:

Schedule an Appointment Today!

864 Hooper Road Endwell , NY 13760

(607) 484-0061

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