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973-408-9183 Virtual Exam
  • About Us
    • Meet Dr. Zeifman
    • Meet the Team
    • Office Tour
    • Community Sponsorship
    • Careers
    • Blog
  • New Patients
    • Why Choose Us
    • Your First Visit
    • Insurance & Finances
    • Patient Forms
    • Patient Rewards
  • Our Treatments
    • Metal Braces
    • Clear Braces
    • Invisalign
    • Invisalign for Teens
    • Inbrace
    • Jaw Surgery
    • Ortho for All Ages
      • Adults
      • Teens
      • Children
    • Ortho Info
      • FAQs
      • Ortho Emergencies
      • Caring For Your Braces
      • Retainer Instructions
      • Videos
  • Our Work
    • Before & Afters
    • Testimonials
  • Contact Us
    • Free Consult
    • Virtual Exam
    • Current Patients: Virtual Visit
    • Doctors: Refer a Patient
    • Patients: Refer a Friend
Virtual Exam

Contact Us:
128 Columbia Turnpike
Florham Park, NJ 07932

973-408-9183

Adult Patient Form

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  • 1. About You

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  • 2. Spouse Information

  • 3. Dental/Orthodontic Insurance

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  • 4. Medical History

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  • For Women

  • Have you ever had any of the following diseases or medical problems?

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  • 5. Patient Signature

    I understand that the information that I have given today is correct to the best of my knowledge. I also understand confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services that I may need during diagnosis and treatment with my informed consent.

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Contact

128 Colombia Turnpike

Florham Park, NJ 07932

973.408.9183

Hours

Mon: 9:30-3:30

Tues – Wed: 10-8

Thurs: 10-6

Friday: 9:30-2:30

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