Patient Forms

Take an active role in your dental health today.  Download and print any or all of these forms to complete at home and hand in at your next dental appointment.  Or, you may fax forms to (212) 281-6544.

Please complete this form in its entirety if you are new to the Dr. Merrick's Dental Studio family. Please remember to include primary, and secondary insurance, if applicable. Additionally, information about amount of deductible(s) and reimbursement(s) is required.  Submit completed form to the Practice Coordinator at your next appointment or you may fax to the ofice at (212) 281 - 6544.

Please complete this form in its entirety if you are new to the Dr. Merrick's Dental Studio family.  If you are currently a patient and your medical status has changed, please complete this form by updating applicable information.  Submit completed/updated form to the Practice Coordinator at your next appointment or you may fax to the office at (212) 281 - 6544.

Please complete this comprehensive form in its entirety if you are a new patient.  This will better assist the oral health care professionals at Dr. Merrick's Dental Studio understand your needs and concerns.  Submit completed form to the Practice Coordinator at your next appointment or you may fax to the office at (212) 281 - 6544.

HIPAA stands for: Health Insurance Portability and Accountability Act.  This form is for patients to authorize the disclosure of dental and medical information to third party entities.  The use of this form includes providing information for the purpose of insurance claims.  The signing of this form is completely voluntary. Please submit signed form to the Practice Coordinator at your next appointment.  Original signatures are required and therefore cannot be faxed to the office.  Please refer to the HIPAA section under the ABOUT menu tab for more information.

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