274 Madison Ave, Suite 202, New York, NY 10016

Dentist on Madison's philosophy is based on making you feel at ease throughout the course of treatment. Our comfort-enhancing amenities include a state-of the arts technology, sam-day service, onsite laboratory, music, aromatherapy and Netflix entertainment for your relaxation and enjoyment.

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Medical History Form

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Please Fill out our
New Patient Form

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Please Fill out our
Notice of Privacy
Practice Form

Medical History Form

    Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

    Are you under a physician's care now?

    Have you ever been hospitalized or had a major operation?

    Have you ever had a serious head or neck injury?

    Are you taking any medications, pills, or drugs?

    Do you take, or have you taken, Phen-Fen or Redux?

    Have you ever taken Fosamax, Boniva, Actonel or any other
    medications containing

    Are you on a special diet?

    Do you use tobacco?

    Do you use controlled substances?

    Women Are You...

    Are you allergic to any of the following?

    Do you have, or have you had, any of the following?

    AIDS/HIV Positive:

    Cortisone Medicine:


    Radiation Treatments:

    Alzheimer's Disease:


    Hepatitis A:

    Recent Weight Loss:


    Drug Addiction:

    Hepatitis B or C:

    Renal Dialysis:


    Easily Winded:


    Rheumatic Fever:



    High Blood Pressure:



    Epilepsy or Seizures:

    High Cholesterol:

    Scarlet Fever:

    Artificial Heart Valve:

    Excessive Bleeding:

    Hives or Rash:


    Artificial Joint:

    Excessive Thirst:


    Sickle Cell Disease:


    Fainting Spells/Dizziness:

    Irregular Heartbeat:

    Sinus Trouble:

    Blood Disease:

    Frequent Cough:

    Kidney Problems:

    Spina Bifida:

    Blood Transfusion:

    Frequent Diarrhea:


    Stomach/Intestinal Disease:

    Breathing Problems:

    Frequent Headaches:

    Liver Disease:


    Bruise Easily:

    Genital Herpes:

    Low Blood Pressure:

    Swelling of Limbs:



    Lung Disease:

    Thyroid Disease:


    Hay Fever:

    Mitral Valve Prolapse:


    Chest Pains:

    Heart Attack/Failure:



    Cold Sores/Fever Blisters:

    Heart Murmur:

    Pain in Jaw Joints:

    Tumors or Growths:

    Congenital Heart Disorder:

    Heart Pacemaker:

    Parathyroid Disease:



    Heart Trouble/Disease:

    Psychiatric Care:

    Venereal Disease:

    Have you ever-had any serious illness not listed above?

    To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

    Signature of Patient, Parent or Guardian:

    Patient Information

      If Student

      Dental Insurance Information:

      Do you have any additional insurance? If so, please complete the following section

      Patient Dental History:

      Do your gums bleed while brushing or flossing?

      Are your teeth sensitive to hot or cold liquids/food?

      Do you feel pain in any of your teeth?

      Do you have any sores or lumps in/near your mouth?

      Do you have a concern with snoring?

      Do you have frequent headaches?

      Do you clench or grind your teeth?

      Have you ever had any prolonged bleeding following extractions?

      Do you wear dentures/partials?

      Name and Location of Previous Dentist

      Do you like your smile?

      Have you ever had orthodontic treatment?

      Have your teeth shifted since?

      Signature of Patient, Parent or Guardian:

      Signature of patient/responsible party certifies that you have read and completed the above information to the best of my knowledge. I authorize and request my insurance company to pay directly to the dentist insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

      Please Fill out our Notice of Privacy Practice Form

        I have been given a copy of Southampton Aesthetic Dentistry. Notice of Privacy Practices (”Notice”), which describes how my health information is used and shared. I understand that the Practice has the right to change this notice at any time. I may obtain a copy by contacting the Practice Privacy Offier.

        My signature below acknowledges that I have been provided with a copy of the Notice of Privacy Practices:

        For Facility Use Only: Complete this section if you are unable to obtain a signature If the patient or personal representative is unable or unwilling to sign this Acknowledgment, or the Acknowledgment is not signed for any other reason, state the reason:

        Frequently Asked Questions

        Root canal treatment in New York may be more expensive compared to other parts of the country due to several factors, including:

        • High overhead costs: The cost of running a dental practice in New York can be higher due to higher rent, utilities, and other overhead expenses. These costs may be passed on to patients in the form of higher fees for dental procedures.
        • Experienced dental professionals: New York is home to some of the top dental schools and training programs in the country. As a result, many highly experienced dental professionals may charge higher fees for their services.
        • Quality of care: Patients in New York may be willing to pay a premium for high-quality dental care and the latest in dental technology and techniques.

        It's important to note that the cost of root canal treatment can vary depending on the complexity of the procedure, the number of canals in the affected tooth, and other factors. Patients at Dentist On Madison Office can also explore different options for financing their dental care, such as dental insurance, payment plans, or dental discount plans.

        The cost of a single dental implant in New York City typically ranges from $2,000 to $5,000 for the implant itself, and additional costs for the abutment and crown could bring the total cost to between $3,000 and $7,000 or more per tooth. Prices can vary depending on the dentist's experience, materials used, and the complexity of the procedure. To get accurate, up-to-date pricing information, it's best to contact Dentist On Madison office in Midtown, NY directly and inquire about the fees. We may also provide payment plans or work with dental insurance to help manage costs.

        The cost of a dental crown in New York City typically rangeы from $800 to $3,000 or more per tooth, depending on the type of material used (porcelain, porcelain-fused-to-metal, or gold), the dentist's experience, and the location of the dental office. Prices can vary depending on specific factors, like the complexity of dental case, the size of the cavity or injury, the necessity for x-ray. Dental crowns in NY can be expensive due to several reasons such as high cost of living, advanced technology and materials used in dental practices, extensive training and expertise of dentists, and insurance limitations. Contact Midtown, NY Dentist On Madison directly for current pricing information. Payment plans or dental insurance may assist manage expenditures.

        When considering a dental bridge in Midtown, NY, it is essential to understand that the total cost can be influenced by various factors. These include the number of teeth that need to be replaced, the materials used to construct the bridge, and the level of complexity involved in the procedure. Generally, the cost of a dental bridge can range from $1,500 to $5,500 or even more per tooth. It is recommended to consult with a dental professional at Dentist On Madison to determine the precise cost of a dental bridge, as a personalized treatment plan can provide a more accurate estimate. The dentist can assess the individual's specific oral health needs and recommend the most suitable options for treatment. We can also provide information about available financing options and insurance coverage that can assist with the cost of the procedure. Overall, while the cost of a dental bridge in Midtown, NY may seem daunting, it is essential to prioritize dental health and seek appropriate treatment. Consulting with a dentist at Madison can help individuals make informed decisions about their dental care and find options that work best for their specific situation.

        The cost of a dental filling in Midtown, NY can vary depending on several factors such as the size and location of the cavity, the type of material used, and the complexity of the procedure. Generally, the cost of a dental filling can range from $150 to $500 or more per tooth. The type of filling material used can also influence the cost. For instance, composite fillings are generally more expensive than amalgam fillings, but they are tooth-colored and provide a more natural-looking result. On the other hand, amalgam fillings are silver-colored and may not blend in as well with the natural teeth. It is important to note that dental insurance plans may cover some or all of the cost of dental fillings, depending on the plan and the individual's coverage. Additionally, you can learn about financing options or payment plans at Dentist On Madison to help individuals manage the cost of treatment.

        Dental implant surgery at Dentist On Madison, NY is usually performed under local anesthesia, which numbs the area being treated and minimizes discomfort during the procedure. Many people report feeling little to no pain during the implant placement process. After the surgery, some discomfort, swelling, and bruising may occur in the treated area. This discomfort can be managed with over-the-counter pain relievers and cold compresses. Our dentist at Dentist On Madison may also prescribe pain medication to manage any post-operative pain. It is important to follow post-operative instructions carefully to ensure proper healing and minimize any potential discomfort. In general, patients are advised to avoid hard or crunchy foods, smoking, and strenuous physical activity for a few days after the surgery to allow the implant to heal properly. Overall, while some discomfort and mild pain can be expected during the dental implant process, it is generally well-tolerated, and the benefits of having a stable and durable tooth replacement option are well worth it. At Dentist On Madison our dental implants professionals will work with you to minimize any discomfort and ensure the best possible outcome for your dental implant surgery.

        Dental implants are a long-term tooth replacement option that can last for many years, and in some cases, a lifetime. The lifespan of dental implants depends on several factors, such as oral hygiene habits, the location of the implant, the individual's overall health, and the quality of the implant placement and restoration. With proper care and maintenance, including regular dental check-ups and professional cleanings, dental implants can last for 20 years or more. In fact, many dental implant manufacturers provide warranties for their products that last for decades. However, it is important to note that dental implants require the same level of care as natural teeth to ensure their longevity. This includes daily brushing and flossing, as well as avoiding habits that can damage the implant, such as chewing on hard objects or using tobacco products.

        The number of teeth needed for dental implants depends on the individual's specific needs and circumstances. Dental implants can be used to replace a single missing tooth, multiple teeth, or even all teeth in the upper or lower jaw. If a single tooth is missing, a single dental implant can be placed to support a dental crown, which replaces the missing tooth. If multiple teeth are missing, a dental bridge supported by dental implants can be used to replace them. Alternatively, multiple single dental implants can be placed to support individual dental crowns. For individuals who are missing all of their teeth in the upper or lower jaw, a full arch restoration can be created using dental implants at Dentist on Madison. This can involve placing several dental implants to support a fixed bridge or an overdenture.

        The number of teeth needed for a partial denture depends on the extent and location of the missing teeth. A partial denture is a removable dental appliance that replaces one or more missing teeth in the mouth. In general, a partial denture requires at least one or two adjacent natural teeth to provide support and stability. The partial denture fits around the remaining teeth, using clasps or other attachments to hold it in place. The clasps are typically made of a material that blends in with the natural teeth and are designed to be discreet. The number of teeth that can be replaced with a partial denture varies based on the individual's specific needs and circumstances. A partial denture can be used to replace several missing teeth on one side of the mouth or multiple teeth throughout the mouth. The dentist at Dentist On Madison, NY can evaluate all circumstances and variants of mouth restoration and help to choose the most suitable solution.

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