• 973-778-0013

    1030 CLIFTON AVE CLIFTON, NJ, 07013

  • 718-336-6555

    200 CORBIN PLACE BROOKLYN, NY, 11235

PATIENTS WITH DENTAL EMERGENCIES ARE TREATED THE SAME DAY GUARANTEED

Dr.Doktorman offers full range of services in the scope of general dentistry,such as cosmetic composite fillings,root canals,removable dentures of multiple designs,crown and bridges,surgical services and gum treatment. more info…

Dr.Doktorman completed implant residency in NYU.All phases of implant dentistry are performed in our office.We offer implant placement,variety of implant supported restorations both fixed and removable. Our office offers a FREE consultation for the patients interested in implant placement and restorations. more info

Dr. Doktorman offers full range of cosmetic services. With the latest technological advancements, the best treatment plan will be developed for individual needs. To achieve maximum cosmetic results, we use all ceramic restorations, such as veneers or simply non metal invisible clasps on dentures. Our office offers a FREE consultation for patients interested in improving their appearance and smile. more info

Dr. Doktorman completed residency in TMJ disorders in NYU. In our office, we can diagnose and treat TMJ disorders of different origins. The symptoms of TMJ disorders include, but are not limited to, pain, soreness in front of ears, upon chewing, yawning, talking.Frequent headaches, ear pain, ear noises, etc.If you suspect that you may have TMJ related pain, please call our office and schedule an examination. more info

CALL OUR OFFICE AT 973-778-0013

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  • 1.
    Patient Information
  • 2.
    Dental Insurance
  • 3.
    Phone numbers
  • 4.
    Dental History
  • 5.
    Health History
MarriedWidowedSingleMinorSeparatedDivorced MaleFemale
Is patient covered by additional insurance? YesNo
ASSIGNMENT AND RELEASE
I certify that I, and/or my dependent(s), have insurance coverage with
and assign directly to Dr.
all understand insurance that benefits, I amif the financially use of my responsible signature for on all all charges insurance whether or submissions. not paid by insurance. I authorize The such information above-named to the dentist may above-named use my health Insurance care Company(ies) information and and may their discloseagents for benefits the or purpose the of benefits obtaining payable for payment related for services services. and This consent determining will end insurance when my current treatment plan is completed or one year from the date signed below.
Signature of Patient, Parent, Guardian or Personal Representative
Name of Patient, Parent, Guardian or Personal Representative
INCASE OF EMERGENCY, CONTACT
Specify someone who does not live in your household.
Place a mark on “yes” or “no” to indicate if you have had any of the following:
Bad breath
YesNo
Bleeding gums
YesNo
Blisters on lips or mouth
YesNo
Burning sensation on tongue
YesNo
Chew on one side of mouth
YesNo
Cigarette, pipe, or cigar smoking
YesNo
Clicking or popping jaw
YesNo
Dry mouth
YesNo
Fingernail biting
YesNo
Food collection between the teeth
YesNo
Foreign objects
YesNo
Grinding teeth
YesNo
Gums swollen or tender
YesNo
Jaw pain or tiredness
YesNo
Lip or cheek biting
YesNo
Loose teeth or broken fillings
YesNo
Mouth breathing
YesNo
Mouth pain,brushing
YesNo
Orthodontic treatment
YesNo
Pain around ear
YesNo
Periodontical treatment
YesNo
Sensitivity to cold
YesNo
Sensitivity to heat
YesNo
Sensitivity to sweets
YesNo
Sensitivity when biting
YesNo
Sores or growths in your mouth
YesNo
How often do you floss?
How often do you brush?
Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva. YesNo
Have you ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). YesNo
Place a mark on “yes” or “no” to indicate if you have had any of the following:
AIDS/HIV
YesNo
Anemia
YesNo
Arthritis, Rheumatism
YesNo
Artificial Heart Valves
YesNo
Artificial Joints
YesNo
Asthma
YesNo
Back Problems
YesNo
Bleeding abnormally, with extractions or surgery
YesNo
Blood Disease
YesNo
Cancer
YesNo
Chemical Dependency
YesNo
Chemotherapy
YesNo
Circulatory Problems
YesNo
Congenital Heart Lesions
YesNo
Cortisone Treatments
YesNo
Cough, persistent or bloody
YesNo
Diabetes
YesNo
Emphysema
YesNo
Epilepsy
YesNo
Fainting or dizziness
YesNo
Glaucoma
YesNo
Headaches
YesNo
Heart Murmur
YesNo
Heart Problems
YesNo
Hepatitis
YesNo
Herpes
YesNo
High Blood Pressure
YesNo
Jaundice
YesNo
Jaw Pain
YesNo
Kidney Disease
YesNo
Liver Disease
YesNo
Low Blood Pressure
YesNo
Mitral Valve Prolapse
YesNo
Nervous Problems
YesNo
Pacemaker
YesNo
Psychiatric Care
YesNo
Radiation Treatment
YesNo
Respiratory Disease
YesNo
Rheumatic Fever
YesNo
Scarlet Fever
YesNo
Shortness of Breath
YesNo
Sinus Trouble
YesNo
Skin Rash
YesNo
Special Diet
YesNo
Stroke
YesNo
Swollen Feet or Ankles
YesNo
Swollen Neck Glands
YesNo
Thyroid Problems
YesNo
Tonsillitis
YesNo
Tuberculosis
YesNo
Tumor or growth on head or neck
YesNo
Ulcer
YesNo
Venereal Disease
YesNo
Weight Loss, unexplained
YesNo

Do you wear contact lenses?
YesNo

Are you pregnant?
YesNo
Due date
Are you nursing?
YesNo
Taking birth control pills?
YesNo

MEDICATIONS
List any medications you are currently taking and the correlating diagnosis:

ALLERGIES
AspirinBarbiturates (Sleeping pills)CodeineIodineLatexLocal AnestheticPenicillinSulfaOther
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Dr.Edward Doctorman