The Barlow Building
5454 Wisconsin Avenue, Suite 1550
Chevy Chase MD, 20815

New Patient Intake Form

"*" Fields Required.
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 Washingtonian 
 Google 
 Dr. Oogle 
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Other - Please Specify:

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 Yes  No 
If yes for what?
 Yes  No 

If yes, list medications and reasons for taking and indicate if you take it in AM or PM:
»Do you have or have you had any of the following conditions?
 Yes  No 

If yes, please list:
 
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If yes, list Psychiatrist Name and Phone #

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If yes, how many per day?
 Yes  No 
 Yes  No 
If yes, please list:
 Yes  No 
If so, which one?
 Yes  No 
If so, please explain:
 Yes  No 
If so, explain:
»Do you have an allergy to or have you had a bad reaction to:
 Yes  No 
 Yes  No 
 Yes  No 
 Yes  No 
 Yes  No 
 Yes  No 
 Yes  No 
»Women
 Yes  No 
 Yes  No 
 Yes  No 
 Yes  No 
»Men
 Yes  No 
»Disclaimer
I certify that I have read and understand the above. I acknowledge that my questions regarding this form have been answered to my satisfaction. I will not hold my dentist or any other member of the office staff responsible for errors or omissions that I may have made in the completion of this form. I acknowledge that if I make omissions or false statements, my health may be put at risk.
»Financial Policy  (View / Download this policy)
I certify that I have read and agree to the financial policy.
»Photography Policy  (View / Download this policy)
As described, I authorize Dr. Puterman to use my photographs as needed in order to communicate with other doctors who are involved in my care. At no time will any identifying or full face photo be shared.
As described, I authorize Dr. Puterman to use my photographs in order to lecture to and to teach other doctors who are not involved in my care. At no time will any identifying or full face photo be shared.
As described, I authorize Dr. Puterman to use my photographs (without any full face or identifying photos) in order to show other patients, like myself, who may benefit from seeing them. At no time will any identifying or full face photo be shared.
»Privacy Policy  (View / Download this policy)
My signature acknowledges that I have been provided with a copy of the Notice of Privacy Practices.