New Patient Form

Office Location

Patient Information

Patient is:

School, College, or University

Employment

Parent or Guardian

Parent or Guardian

Spouse

Emergency Contact

Responsible Party

Primary Insurance Information

Insurance Company

Secondary Insurance Information

Insurance Company

Patient Medical History

Check Applicable:
Hospitalizations:

Please detail any surgical operations or serious illnesses within the last five years.

Medications:

Please list both prescription and non-prescription medications.

Allergies:
Conditions:

Please check if patient has or has ever had the following:

Patient Dental History

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Authorization and Release

By submiting this form I authorize Frankel Dentistry to release health and/or account information identifying me under the following terms and conditions:

  • 1 . All detailed personal information (such as: full treatment, health and account)
  • 2. To whom may the information be released:
Name
Home / Cell Number
Relationship
Permission to Leave a Detailed Message
SELF
SELF
Self Leave detailed Message?
Person 1Leave detailed Mesage
Person 2Leave detailed Mesage
Person 3Leave detailed Mesage
Person 4Leave detailed Mesage
Person 5Leave detailed Mesage

I understand that I may revoke this authorization in writing at any time, except for the information that has already been disclosed by Frankel & Puhl Dentistry in reliance on this authorization, by sending a written revocation to:

Frankel Dentistry, 5012 Talmadge Road, Toledo, Ohio 43623 OR Frankel & Puhl Dentistry, 4359 Keystone Drive Ste 100, Maumee, Ohio 43537

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examinations rendered to me or my child during the period of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group 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.

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Patient Testimonials

Very professional, positive experience having my teeth cleaned. From the friendly greeting by the receptionist, to the assistant who escorted me to my room, to the hygienist who cleaned my teeth--and the final check-in by Dr. Frankel, I felt well treated and in great hands.

Patrice K.

Excellent as always. My wife & I have been going to Frankel's since the late '60's, and have no plans to change.

Richard McCarthy

Thanks to the amazing staff who did an Awesome job at making my 5 yr olds first experience with a filling a positive one. The first thing she said when she was finished was "everyone is so nice."

Cara Elis

Everyone at the office was smiling, respectful and very nice. They called you by your first name and shook your hand. I highly recommend Dr. Frankel and his staff.

Patient

There is no doubt in my mind that Frankel Dentistry sets the standard for quality and courteous dental care. I have not yet been disappointed by the care I have received in any of my visits.

Robert Wagner
Schedule an Appointment

Visit Dr. Frankel and Dr. Puhl for outstanding dental care. From our Toledo and Maumee dental offices, we welcome patients from Sylvania, Ottawa Hills, Perrysburg, Whitehouse, and the surrounding areas.

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New Patient?

Are you interested in signing up as a new patient?
If so, please follow the link to our new patient form,
and bring it with you on your first visit.New Patient Form