Dr. Rosenbaum

Boston Dentist TMJ Treatment In Boston Massachusetts
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Boston Periodontics Massachusetts Replace Teeth
Dental Implant Boston MA Implant Dentist In Massachusetts

IF YOU HAVE BEEN IN AN ACCIDENT

Emergencies are welcome

If you are going to be a new patient of ours, you may like to save yourself some time by filling out the following form. We have given you the choice of filling out an electronic form and a printable form. Click here for the printable form and when the page fully loads, select the print option from your browser's menu. When the form has been printed, please fill it out to the best of your knowledge and bring it into the office.

Our electronic form can be found below. Simply fill out the empty fields and select the appropriate options for your answers.

1. Date of accident:

2. Was there head, neck, face, or jaw pain of any type before the accident?

Y N

3. Did you lose consciousness?

Y N

4. Did you go to a hospital?

Y N

5. Did you go to a hospital in an ambulance?

Y N

6. If you went to a hospital, what kind of X-rays were taken?:

7. If you went to a hospital, what kind of treatment did you receive?:

8. If you went to a hospital, was medication prescribed?

Y N

9. If you went to a hospital, were you given a neck collar?

Y N

10. In chronological order what types of doctors did you see before coming to this office and what treatments did you receive from that doctor?

11. Do you have a lawyer?

Y N

12. Who is your lawyer?:

13. Do you have a TMD or other headache?

Y N

14. Do you have a toothache of non-dental origin?

Y N

15. Would you like to tell us anything else?

NOTE: Please make sure you bring a copy of your inurance claim form so we may know where to send it.