Submit New Patient Information

Thank you for choosing Larchmont Dental Associates. If you are a new patient, please fill out the information below and schedule your first appointment.

Patient Information

Required fields indicated with an asterisk (*)

* Patient's First Name:

* Patient's Last Name:

*Patient's Email Address:

* Street Address:


Zip Code:

* Home Phone:

Work Phone:



Social Security Number:

Date Of Birth:

Sex: Male Female

Insurance Information

Do You Have Dental Insurance?
If No, skip to next section :  Yes No

Name Of Insurance Company:

Name Of Insured Employee:

S.S. # of Insured:

Insured Date:

Employer Name:

Employer Address:

Policy/Group Number:

Insurance Company Number:

Additional information

Emergency Contact Phone:

Who referred you to our office? :

Has Any Family Member Been Seen In Our Office? :  Yes No

If Yes, Please List Their Names Here:

When was the last time you visited the Dentist? :

How would you describe your present Dental condition? :

Please enter here any additional information regarding your dental condition, specific dental problems, or additional comments you would like to accompany with your form. :

Please Enter the word below in the text field to continue :