Dr. Amit Rajani

Patient Forms

Save time waiting in our office by filling out necessary forms online. Feel free to give us a call if you have any questions.

New Patient Packet - English

New Patient Packet - Spanish

Page 1: Contact Information and Insurance (English)

Page 2-3: Dental and Medical History (English)

Page 4: Financial and Cancellation Policies (English)

Page 5: HIPAA and Consent Form (English)

Page 1: Contact Information and Insurance (Spanish)

Page 2-3: Dental and Medical History (Spanish)

Page 4: Financial and Cancellation Policies (Spanish)

Page 5: HIPAA and Consent Form (Spanish)

Have Questions? Get in Touch
If you have difficulty using our website, please email us or call us at (845) 669-6638
View the ADA Accessibility Statement
We are pleased to announce the office is OPEN and seeing patients for routine and emergency care as of June 8th, 2020. 
Please call us at 914-423-1900 or text at 855-458-9344 to schedule an appointment! We look forward to seeing you soon!