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New Patient Form

- Step 1 of 5

Patient Information

Is the Patient a Child or Adult? *

Child
Adult

Patient's Name *

First

Last

Date of Birth *

Age *

Gender *

Male
Female

Height *

Weight *

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Home Phone

Work Phone

Email Address *

Patient's Dentist (of Adult/Child) *

Address (Dentist) *

Patient's Physician (of Adult)

Patient's Oral Surgeon (of Adult/Child)

Patient's Pediatrician (of Child)

Summer/School Camp

Who May We Thank for Referring You to Our Office?

Privacy *

I have read and accept the Privacy Policy.

Confidential Responsible Party Information

(If patient is under 18)

Name

First

Last

Marital Status

Single
Married
Widowed
Divorced

Residence

Own
Rent

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

How Long Have You Lived at This Address?

Cell Phone

Work Phone

Previous Address (If Less Than 3 Years)

Address Line 1

Address Line 2

City

State

Zip Code

Social Security #

Date of Birth

Relationship to Patient

Employer

Occupation

Number of Years Employed

Spouse's Name

Relationship to Patient

Employer

Occupation

Number of Years Employed

Social Security #

Date of Birth

Insurance Information

(If patient is under 18)

Policy Holder’s Name

First

Last

Social Security #

Insurance Company

Group No.

Union Local No.

Insurance Co. Address

Address Line 1

Address Line 2

City

State

Zip Code

Insurance Co. Phone

Employer

Marital Status

Single
Married
Widowed
Divorced

Cell Phone

Work Phone

Email

Date of Birth

Policy Holder’s Employer

Do You Have Dual Coverage?

Yes
No

If Yes, What is the Policy Holder’s Name?

Social Security #

Insurance Company

Group No.

Union Local No.

Insurance Company Address

Address Line 1

Address Line 2

City

State

Zip Code

Insurance Company Phone

Policy Holder’s Employer

Emergency Information

Name of Nearest Relative Not Living With You

First

Last

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone

Work Phone

Relationship to Patient

I understand that where appropriate, credit bureau reports may be obtained.

Patient's Medical History

Please answer the following questions to the best of your knowledge.

Is patient in good health? *

Yes
No

Does patient have any history of major illness? *

Yes
No

Has patient ever been under the care of a physician for illness? *

Yes
No

Please explain.

Has patient ever been hospitalized? *

Yes
No

If yes, for what?

What is the date of the last examination by a physician?

Does patient bruise easily? *

Yes
No

Has patient ever required a blood transfusion? *

Yes
No

Does patient have tendency to colds? *

Yes
No

Does patient get sore throats? *

Yes
No

Have tonsils and/ or adenoids been removed? *

Yes
No

If yes, at what age?

Does patient have chronic ear pain or infections? *

Yes
No

Does patient take sedatives, tranquilizers, sleeping pills or medicine to relax? *

Yes
No

Does patient have trouble sleeping? *

Yes
No

Does patient snore when sleeping? *

Yes
No

Has the patient traveled to Guinea, Liberia, or Sierra Leone in the past 21 days? *

Yes
No

If yes, please list dates.

Is patient feeling feverish? *

Yes
No

List any drugs or medications now or previously taken. *

Does the patient have any known allergies? *

Patient's Dental History

What is the date of patient’s last dental examination or treatment?

Has patient had any serious problems associated with previous dental treatment? *

Yes
No

Have there been any injuries to the face, mouth or teeth? *

Yes
No

Has there been any treatment for problems of the jaw joint or for facial muscle spasms? *

Yes
No

Has the patient ever sucked a thumb or fingers? *

Yes
No

if yes, until what age?

Does the patient have any speech problems? *

Yes
No

Is the patient a mouth breather? *

Yes
No

If yes, at what times?

Have you been informed of any missing or extra teeth? *

Yes
No

Does food catch or collect between teeth? *

Yes
No

Does the patient clench or grind their teeth? *

Yes
No

Is there clicking, popping or grating noise from the patient’s jaw when chewing? *

Yes
No

Is there numbness or tingling associated with the patient’s mouth or face? *

Yes
No

Has the patient ever had orthodontic treatment or been treated for a bad bite? *

Yes
No

Has an orthodontist been consulted previously? *

Yes
No

Has the patient ever had periodontal (gum) disease? *

Yes
No

Has either parent had orthodontic treatment? *

Yes
No

Has either parent had periodontal disease? *

Yes
No

Does the patient use a mouthguard during sports? *

Yes
No

List any musical instruments played.

Patient's Name *

First

Last

Please check all that are important to you and provide us any additional information you would like to share.

(If patient is under 18)

1. Treatment Time *

I have an event and I want to show off my smile
I will be moving or leaving the area
Build my confidence
Just because
Other

If other, please specify.

2. Frequency of Visits: *

I have a full schedule with work and/or after school activities
I will be driving a long distance to the appointments
Time is precious to me

3. Appearance of Braces: I don’t want braces to show because... *

Of my career
I don’t like the way braces look
Confidence
Just because

4. Comfort: *

I am concerned about pain and discomfort
Doctors make me nervous
Other

If other, please specify.

5. Price:

I want to discuss an interest-free payment plan

Please rest assured that we are not willing to let finances stand in the way of a patient’s desired treatment. We will work to find a financial arrangement that will fit within your budget.

6. Best Result: *

Cosmetic fix, not the overall bite
Beautiful smile with a healthy occlusion

Explain your desired results.

Privacy Policy *

I have read and accept the of the Privacy Policy

Name

Forest Hills Orthodontic Associates in Forest Hills, NY

Get Started

Today

We Can’t Wait To See You!

Start your journey to a healthy, beautiful smile by scheduling your free consult with Dr. Mizrahi and our friendly, expert orthodontic team.

Request Free Consult

patient REviews

Experience 5-Star Care

Creating lasting relationships with our patients means we’ve been able to see the smiles of multiple family generations.

Genesis T.

First time going to this location, and my experience was amazing!, quick and great service. The assistants were amazing at helping and explaining the service provided. Showed great attention to my child and her needs. Will recommend!

Amelia A.

From the beginning, the staff has always been welcoming and friendly, which makes every visit feel comfortable. The office is really clean and organized, and appointments usually run on time which I appreciate. Dr. Mizrahi takes the time to explain everything so I understand what’s going on with my treatment, and he’s patient if I have any questions. I’ve noticed a big improvement in my teeth since I started, and it feels good to see the progress over time. Anytime I’ve needed adjustments or had concerns, they’ve always handled it really well and made sure I felt taken care of. Overall, I’ve had a really good experience here and I’d definitely recommend Dr. Mizrahi and his team to anyone who needs braces or orthodontic care.

Naomi P.

Great experience! Dr. Mizrahi made sure my teeth were perfectly straight!

Jackie K

I would like to take this opportunity to let others know how Dr. Mizrahi is definitely a master of his trade. When I came to Dr. Mizrahi I had several teeth that had shifted in my mouth due to missing teeth in my adolescent years as I was decades older when I saw him. He assured me my teeth would be brought back to the beautiful smile I had many years ago. There was also one tooth that several dentists told me would need to be pulled because it was so loose, Dr. Mizrahi told me not to have the tooth pulled, it will be stronger after the straightening of the teeth. Well, it’s been 8 years since Dr. Mizrahi straighten my teeth beautifully and I have not had to have the so called “loose tooth” pulled, in fact, my periodontist said it looks like you will be able to keep that tooth for the rest of your life. I can’t thank Dr. Mizrahi enough for his insight and making my beautiful smile again. I highly recommend him to anyone that needs orthodontic care.

Kristine J.

I am a patient of Dr. Mizrahi for almost 2 years. We having been working on my teeth with Invisalign. Dr. Mizrahi is very caring and always makes sure his patients are comfortable and makes sure to explain the process. The most important is the front desk staff- they are really professional and easy to work with.

Review update:
Working with Dr. Mizrahi has been an incredibly smooth and encouraging experience, AND with amazing results!
My main concern was fixing my bottom teeth, and the transformation has been unbelievable. The before-and-after photos are shocking—in the best way. The final result is absolutely beautiful, and I couldn’t be happier.
Dr. Mizrahi and his team guided me through every step of the process, making everything feel simple and stress-free. I’m truly grateful for their care and expertise! If you need Invisalign reach out to Dr Mizrahi!

J L.

Five stars for the management and customer service of this office. Yanexa, manager took her time to answer questions about my insurance and what benefits would be available. Really appreciate that because some offices do not take the time or try to accommodate you. The front desk staff was friendly and polite. Fantastic customer service!

ADEEB A.

Dr. Mizrahi provided a thorough and detailed assessment of my daughter's case. He put us both at ease. She decided she wanted him to treat her underbite.

Diego F.

Welcoming, friendly and very professional.

Tishara B.

My experience with Dr. Mizrahi and his team has been nothing short of exceptional. From the very first visit, I felt welcomed and at ease. Dr. Mizrahi is not only highly knowledgeable, but also incredibly attentive, very nice, and approachable. He takes the time to listen to your concerns and explain each step of the process clearly, which I truly appreciate.

The dental assistants are also wonderful, gentle, professional, and always make sure you’re comfortable throughout the visit.

The front desk staff are always friendly, patient, and accommodating when it comes to scheduling or answering questions. Every visit has been smooth and pleasant, thanks to their professionalism and kindness. I’m really happy I chose Forest Hills Orthodontics and would confidently recommend them to anyone seeking expert care in a welcoming environment.

Raul A.

I’ve had an amazing experience at Forest Hills Orthodontics! Dr. Mizrahi is very knowledgeable, extremely nice, patient, and takes the time to explain everything clearly. From the dental assistants and treatment coordinators to the front desk, all the ladies who work in the office are incredibly friendly and welcoming, which made every visit feel comfortable. I’ve never had any issues scheduling appointments, and they always return my calls promptly. From start to finish, the service has been top-notch. This place is easily one of the best orthodontist offices in Queens, and I would definitely recommend it to anyone looking for quality care with a personal touch!

Patient Testimonial Forest Hills Orthodontic Associates in Forest Hills, NY

our location

Come Visit Us

We’re excited to meet you and have you start your dream smile journey at Forest Hills Orthodontic Associates.

Location

Forest Hills110-35 Jewel Ave.
Forest Hills, NY 11375

Phone

(718) 897-6666

Forest Hills, NY

Request Free Consult

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Forest Hills, NY
(718) 897-6666

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