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

New Patient Intake Form

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 Washingtonian 
 Google 
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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?
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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?
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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:
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 Yes  No 
 Yes  No 
 Yes  No 
 Yes  No 
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»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)
I understand that photography of my condition may be necessary and I authorize Dr. Puterman to take and utilize photographs as described. I understand that my privacy will be maintained and identifying features will not 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.