Who told you about us?



Dental History

Medical History

Medical History



I also authorize Dr. Mizrahi to perform all recommended treatment mutually agreed upon by me and to use the appropriate medication and therapy indicated for such treatment in connection with (patient name) I












PRIVACY CONSENT



Patient Advisory and Acknowledgment

Receiving Dental Treatment During the COVID-19 Pandemic


PLEASE ANSWER “YES” OR “NO” WITH YOUR INITIALS, TO THE FOLLOWING QUESTIONS: .