Patient Forms

The following forms can be downloaded to your computer and printed at home. In order for our doctors to provide a complete and comprehensive dental opinion it is important that they review all of your medical information. Please be prepared to provide this information to our office along with your current dental insurance information. Below are links to our patient information forms. If you have any questions when filling out these forms, please do the best you can and our staff will assist you with your questions on the day of your visit.

• New Patient Form for Adults
• New Patient Form for Children

Please note: These documents are in Adobe® PDF format. They require Adobe Reader to be viewed. If you do not have Adobe Reader, you can download it for free by clicking here.

Contact Us Form

To schedule an appointment, please contact our office directly. For more information about our services, or any other questions or comments, please complete the form below.

Total Dental Care of Middle Island
699 Middle Country Road
Middle Island, NY 11953
Tel: 1.800.PLAN.TDC

Office Hours
Monday-Thursday: 9:00 to 7:30
Friday: 9:00 to 6:30
Saturday: 8:00 to 1:00

Note: Do not use this form for an emergency!
Total Dental Care of Middle Island is not affiliated with any other Total Dental Care.

* Name:
Address:
Suite:
City:
State:
Country:		United States Canada Mexico United Kingdom Ireland France Italy Denmark Russia Brussels Netherlands Greece Turkey Israel Monaco Switzerland Sweden Germany Japan Singapore China - Hong Kong Korea Malaysia Brazil Colombia Caribbean Peru Argentina Other
Phone:
Fax:
* E-Mail:
Are you currently a patient?		Yes No
If not, how did you hear about our practice:		Referral from friend/co-worker Physician Advice Web Search Other
Questions/Comments:
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Please be aware that this is a non-secure communication.

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