New Patient Forms

399 East 72nd Street Suite 1A
Between First and York Avenues
New York, NY 10021
(888) 290-2240 Toll-free or 212-988-8822
(212) 988-8858 Fax
E-mail: DrSimon@DrSimonRosenberg.com

We now are adding the new patient forms to our web site. The registration form, along with the HIPAA privacy form, the Medical and Dental History forms are now handled by SubmitPatientForms.com through their
Secure 128-bit encryption web site. When you go to that page you will notice the HTTPS designation in the URL and the closed lock in the lower right corner of your browser. All information is confidential and meets or exceeds all state and federal privacy requirements.

Please click on New Patient Register Here logo below and when you click the SUBMIT button and it will be securely transmitted to the office.

If you wish to fill the medical or dental forms in PDF format out by hand, click on the links at the left

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		The information contained in this web site is for the sole purpose of identifying dental care or treatment which may be available from a qualified dentist. This web site does not offer any form of medical or dental advice. Simon W. Rosenberg, D.M.D., does not represent, warrant or guarantee that any specific treatment is appropriate to your present or future dental needs. Please contact a dentist or hospital if you are experiencing dental pain or have a dental emergency. The rights to the names of products or services mentioned are the property of their respective registered trademark owners.

capital_one_logo care_credit_logo

We are pleased to offer a choice of Capital One Healthcare Finance or Care Credit Health Finance to our patients. Both Plans are a convenient, no initial payment, low monthly payment plan
for dental treatments of $1,000 to $25,000.

(Ask about the no-interest-same-as-cash options --
For treatment under $1000 there's a no interest for 90 days. There’s no interest for one year if treatment is over $1000.)

Offering these Healthcare Finance Plans allows us to make the smile you've always wanted affordable.

If you have any questions, please feel free to contact me

E-mail: DrSimon@DrSimonRosenberg.com

(888) 290-2240
(212) 988-8858 Fax
(800) 576-6628 Emergency Page Operator


	1975 1978 (MADA 1975) 1978 (Boston 1975) 1981 1984 Dr. Rosenberg has been a member of these societies since the above dates.