New Patient Intake Form

Please correct the errors described below.


A Master of The Academy of General Dentistry


THANK YOU for contacting us for an appointment.

Our office is ‘ Dedicated to Preserving Your Teeth ‘ through health and restorative services.

We are a small, one dentist, private practice. >>( )> . Dr DeLucia is a cosmetic restorative dentist... and yes Dr DeLucia performs all the dental cleanings.

***We only treat people ages 65 and above *** as Dr DeLucia has a special interest in the diseases and disorders of people within this age group.

We only intake a certain number of each insurance to avoid the office being inundated with any single insurance. We give equal opportunities to all the insurances.. Any changes in insurance will require the patient to be inactivated and reactivated into the office on the month that we begin to take that insurance again. All insurance changes must be presented prior to making your next appointment to determine eligibility to re-enter the practice under that plan.

Oh....and one more thing....if you have another dentist in another state or country please be aware that for our patients to remain a patient, ALL x-rays and ALL restorative treatment must be performed by Dr DeLucia once you are a patient of record.. Cleanings can be performed by a dentist in another location to help our patients that are 'snow birds' or ''southern country birds'. This is important for treatment consistency and predictable results. Thank you for understanding our responsibility to you as our patient.

We need some information prior scheduling you into our office.

To fill out the information below, please check your insurance card or your insurance website or call your insurance company.

Check two of the boxes below that apply to your particular insurance:

For us to obtain your insurance information, we need a copy of the front and the back of your insurance card emailed to

Pease check all areas that apply to your existing situation. At least one box must be checked to schedule your appointment:

In dentistry, we find that due to emergencies and unforeseen events with certain cases, it is impossible to avoid running behind. Our office does not cut corners or speed up procedures to stay on time. Please notate, which of the following statements best simulates your perspective.

**THANK YOU FOR YOUR GOOD HYGIENE DURING YOUR APPOINTMENT** . We have upholstered chairs and desire to keep them clean for all patients. Our dental chair has a 300 pound weight limit. If your weight exceeds this, please call the office for special assistance.

Please be informed that we reserve the right to dismiss patients with an adversarial attitudes and displays of anger; as a dentist-patient relationship should be one of trust and respect.


Thank you for your information.

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