Patient Forms

To help expedite patient registration and updating records many of our forms that patients need to complete can be downloaded below and completed in advance.  You will need a PDF viewing software such as Adobe Reader which can be downloaded from their website by clicking on the adjacent icon.

Health History For 

(Adults-Ages 13 & older)

To provide the best possible dental and oral healthcare it necessary to have a comprehensive understanding of the patient’s overall health. The past and present health conditions that a patients has had and the medications they taking are important factors in determining the proper diagnosis and treatment for many oral conditions.  To accurately obtain this information and help expedite the process we encourage patients to download the appropriate health history forms and complete them in advance of their appointment.

Release of Records Request (from prior office)
Release of Records TO BDG.pdf
Adobe Acrobat document [589.0 KB]
New Patient Adult Health History Paperwork
New Patient Health History Paperwork.pdf
Adobe Acrobat document [494.1 KB]
New Patient Child Health History Paperwork
New Patient Child Health History HIPPA [...]
Adobe Acrobat document [441.0 KB]

The above forms include the following: 

Patient Medical and Dental History Form

This form is mandatory for new patients. To expedite your visit, print this form, fill it out and bring it with you for your first visit.

Privacy Notice

Please read over and sign our Notice of Privacy Practices, acknowledging our privacy policy. This form should also be brought to your first appointment. 

Patient Account Information 

This form includes family payment information, dental insurance information, secondary dental insurance information, and medical insurance information.

Call for an

Appointment Today!

607-563-2333

Benjamin Dental Group

60 Union Street @ Pearl

P.O. Box 27

Sidney, NY, 13838

Telephone: 607-563-2333

Fax:            607-563-8946

Email:

Info@BenjaminDental.com

Open 9:00a.m. - 5:15p.m.

____________________

 

Scott D. Benjamin, D.D.S.

 

Office Administrator

    Wendy Johnson

 

Business Manager

    Marie Benjamin, C.P.A.

 

Clinical Coordinator

    Ayla Martin, C.D.A.

 

Hygiene Staff

    Kim Ives, R.D.H.

    Lorinda Edwards, R.D.H.

Keep Your Mouth Healthy!

What is the best preventive care for your teeth? Find out how to make your next visit easier and more pleasant.

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