Customize Your Preferences Name* First Last Phone*Email* I am:*A New PatientA Existing PatientReferred by:*During my dental visit, I would usually prefer to:*Watch TVWatch A MovieWatch NetflixWatch HuluListen to MusicHave QuietIf I were to watch TV, my favorite channels are:If I were to watch a movie I would prefer to watch:*ComedyAdventureActionDramaDocumentaryThrillerMy favorite type of music is:*RockClassic RockPopAlternativeJazzClassicalOperaBroadway HitsSpa / RelaxingRhythm and BluesCountryMy Favorite groups / artists are:I would prefer to have wireless headphones during treatment*YesNoI would prefer to have Nitrous (laughing gas) during treatment*YesNoThe types of appointments I prefer are:*MorningLunch TimeAfternoonAnytimeI prefer to be seen:*During the WeekOn the WeekendsDoesn't MatterAdditional Special Requests* I accept the Terms of Use * CommentsThis field is for validation purposes and should be left unchanged. Marc Lazare, DDS 115 East 61st St., Suite 14ANew York, NY 10065Phone: (212) 861-2599E-mail: [email protected]
