Dental Clinic in Philadelphia - Site Logo
Call Now : 267-463-2777
7052-56 Frankford Ave | Philadelphia. PA 19135
Located 2 Blocks from Frankford & Cottman Avenues | Directions
office@spilkiadentistry.com

New Patient Registration

Please note that it is important to fill in all the fields before submitting. Thank you.
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About You

Title : Mr Mrs Ms Dr
Patient Name :
Last Name*
First Name*
Middle Name
Prefer to be called : Sex : Male Female Age:
Patient's SSN :
Patient's Birthday :
Home Address:*
City
State
Zip
Apt#
Home Phone:* ()--
Work Phone: ()---
Cell Phone : ()--
E-mail:*
Do you have Dental Insurance? Yes No
Marital Status: Single Married Divorced/Separated Widowed
Employer:
Subscriber :
Insurance Company :
Subscriber's SSN :
Subscriber's Birthday :
Where & when are best times to reach you?
How did you hear about us?
Whom may we thank for this referral?
Other family members seen by us:
Previous dentist:
Who is financially responsible for this account?
Nearest Relative Not Living with You
His/Her Parson: Relationship:
Home Phone: ()--
Work Phone: ()---

Medical History

Do you have a personal physician? Yes No
Physician’s Name:
Telephone Home: () - -
Date of last visit:
Your current physical health is: Good Fair Poor
Are you currently under the care of a physician? Yes No
If Yes, Please Explain:  
Do you smoke or use tobacco in any other form? Yes No
Have you had any metal rods, pins or implants? Yes No
Are you taking any prescription or over-the-counter drugs? Yes No
If Yes, Please Explain:  
Do you get cold sores? Yes No
Do you wear a cardiac pacemaker, or have you had heart surgery? Yes No
If Yes, When?  
Are you required to take any medication before your dental visit? Yes No
If Yes, What?  
For women:
Are you using a prescribed method of birth control? Yes No
Are you pregnant? Week #: Yes No
Are you nursing? Yes No
Have you ever had any of the following diseases or medical problems
Yes No Rheumatic Fever Yes No Thyroid Disease
Yes No Seizure Disorder Yes No Heart Disease
Yes No Anemia Yes No Kidney Disease
Yes No Heart Murmur (or MVP) Yes No Asthma
Yes No Venereal Disease Yes No High Blood Pressure
Yes No Diabetes Yes No Bleeding Problems
Yes No Tuberculosis Yes No Are you nursing
Yes No Cancer Yes No Aids/HIV
Yes No Artificial Joint / Heart Valve Yes No Psychiatric Treatment
Yes No Eating Disorders Yes No History of Endocarditis
Yes No Radiation Therapy: Head / Neck Yes No Alcohol and Drug Abuse
Yes No Arthritis Yes No Liver Disease
Yes No Hepatitis Type: A B C
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following?
Yes No Aspirin Yes No Erythromycin
Yes No Penicillin Yes No Sulfa drugs
Yes No Jewelry / Metals Yes No Codeine
Yes No Anesthetic (Novocain, etc.) Yes No Tetracycline
Yes No Latex Yes No Other
Please list any other drugs / Materials that you are allergic to:
Are You Now Taking:
Drugs for high blood pressure? Yes No Drugs for sleep? Yes No
Cortisone, steroids or ACTH? Yes No Insulin? Yes No
Tranquilizers or sedatives? Yes No Antibiotics? Yes No
Anticoagulants or blood thinner? Yes No
Please list any medications you are currently taking?

Dental Health and Appearance

Reason for visit:
Approximate date of last dental visit :
What is your primary concern that you would like us to address first?
When would you like us to start treatments?
Have you ever had any serious problem associated with previous dental treatment or any dental emergencies? Yes No
If Yes, Please Explain:  
What, if anything, has happened in previous experiences at the dentist that was reason not to return?
Do you ever feel (or have you ever been told) that you don't have fresh breath? Yes No
How often do you brush your teeth? time(s) a
How often do you floss? time(s) a
What type of brush do you use? Manual Powered
Do you avoid brushing any part of your mouth because of pain? Yes No
If Yes, What part?  
Which foods cause you twinges of pain : Hot Cold Sweet Sour None
Do your gums feel tender or swollen? Yes No
Do you chew on only one side of your mouth? Yes No
If so, Please Explain:  
Do you clench or girnd your jaws while sleeping or during the day? Yes No
Do your jaws ever feel tired? Yes No
Are you delighted with your smile? Yes No
Please rate your smile from 1 to 10 (1=I hate my smile, 10=Awesome) :
Would you like to have whiter teeth? Yes No
If you had a magic wand, what, if anything, would you change about your smile?
What (if any) personal or professional benefit might you gain if you had a gorgeous smile?
Do you have any special occastions coming up?

* I Understand That Payment Is Due At Time of Service.
I will pay today by:   CASH CHECK CREDIT CARD CARE CREDIT
* formation is true. I authorize the release of information to the insurance company. I will allow Dr. David Spilkia, DMD and his associates to discuss the conditions with my physician(s) and to request medical information from them. I authorize the office of David Spilkia, DMD to obtain and verify a credit report.
* The information and health history and preceding answers are true and correct to the best of my knowledge. I authorize and give consent to perform dental services agreed between doctor and patient and/or guardian to be necessary or advisable, including the use of local anesthesia and other medications as indicated. I agree that, regardless of insurance coverage, I am responsible for payment for services rendered. If I ever have any changes in my health or if my medication change I will, without fail, inform the doctor at my next appointment.


*Signature
Date
Dental Clinic in Philadelphia - Special Offer
  • Rating: 5 Dental Clinic in Philadelphia - Five Star Reviews By G. Parker

    David Spilkia Family and Cosmetic Dentistry
    There are many things that set Dr. David Spilkia's practice apart from the rest from the rest. At David Spilkia, DMD, Dr. David Spilkia builds personal relationships with his patients, the staff is all warm and inviting, and the office and equipment is bright, shiny and new. They offer Saturday alternately too, and he is very accommodating in general. All in all, a very customer care focused practice, which is lacking pretty much everywhere else. Everyone at David Spilkia, DMD, here in Philadelphia, PA is so nice!

    Reviewed by James W.
  • Rating: 5 Dental Clinic in Philadelphia - Five Star Reviews by Charles B

    Dr. Spilkia here in Philadelphia is an honest, reliable and extra friendly cosmetic dentist. Dr. Spilkia is a consummate professional. He is caring, concerned and extremely capable. The work he has done on my teeth has been efficient and painless.

    Charles B.
  • Rating: 5 Dental Clinic in Philadelphia - Five Star Reviews by Tony F.

    Dr. Spilkia here in Philadelphia is an honest, reliable and extra friendly cosmetic dentist. Dr. Spilkia is a consummate professional. He is caring, concerned and extremely capable. The work he has done on my teeth has been efficient and painless.

    Tony F.
  • Rating: 5 Dental Clinic in Philadelphia - Five Star Reviews by Nancy R.

    Dr. David Spilkia is the best cosmetic dentist I've ever had. . He is very friendly and positive, makes you feel comfortable during your appointment and explains everything he is doing. Everyone at David Spilkia, DMD here in Philadelphia, PA is so nice!

    Nancy R.
  • Rating: 5 Dental Clinic in Philadelphia - Five Star Reviews by Mario R.

    I finally found a great cosmetic dentist here in Philadelphia, PA. I really appreciate how friendly and attentive the office staff is. More dentists should learn from the way patients are treated here in David Spilkia, DMD.

    Mario R.
  • Rating: 5 Dental Clinic in Philadelphia - Five Star Reviews by Betty

    I'm 42 years old, and have always been afraid of the dentist, until I came here they made me feel welcome and everybody was so understanding and helpful. they did an amazing job with my teeth and Im so happy now. thank you Dr. David Spilkia and staff for taking the time with me and for been so nice to me.

    Betty
  • Rating: 5 Dental Clinic in Philadelphia - Five Star Reviews by Google User

    Greatest Dentist, not kidding. When they say Gentle Dentist, this is the practice you want to go to. Dr. Spilkia is wonderful and his staff is extremely professional, helpful, and go out of their way to make sure that you feel comfortable! I would definitely recommend this practice to anyone! I already do and have been a patient of his for 12 years!

    Google User
  • Rating: 5 Dental Clinic in Philadelphia - Five Star Reviews by Renee

    I have had such a beautiful experience with Dr. Spilikia staff. They are compassionate and very sensitive to me and my fears. Dr. Spilkia is such a wonderful Dentist. I've been with Dr. Spilkia for a little more than 3 years, and it is always a pleasant visit. Dr. Spilkia and his staff are the best. If you have any phobias of going to the dentist, you have to choose Dr. David Spolkia and his staff, they are so wonderful.

    Renee
  • Rating: 5 Dental Clinic in Philadelphia - Five Star Reviews by Google User

    It's my first time giving a star rating to a dentist but I did like this one. I've been searching for a dentist and found the cleaning to be painful and some locations as they tend to just rip your gums apart. I'd recommend this office because the ladies here treat you like a family member and the place is immaculate (however one spells immaculalte - english isn't my major). anyway, I travel 4-hours from Maryland to Philadelphia just to see this dentist because he's just that good. I'm not kidding. If there were ten stars, then he'd get all ten...anyway before I ramble on and on, I've got to drive back to Maryland so just drop by and the ladies here will help. p.s. they are not hard on the eyes either.

    Google User
  • Rating: 5 Dental Clinic in Philadelphia - Five Star Reviews by Google User

    I have never reviewed a medical professional before, but Dr. David Spilkia is the best cosmetic dentist here in Philadelphia, PA ;( and I've had at least 10 dentists in my lifetime). I've been with him for about 1.5 years now so I feel comfortable recommending him.

    Google User
  • Rating: 5 Dental Clinic in Philadelphia - Five Star Reviews by S. Mcgovern

    Thank you Dr. Spilkia for your caring professional services.In my last visit I spent almost 3 hours as you preformed a root canal and made my new crown. I would never have believed a person could actually nap through a root canal!

    S. Mcgovern
  • Rating: 5 Dental Clinic in Philadelphia - Five Star Reviews by Susan M.

    Experienced dentist, efficient staff, and comfortable decor. Have been a client of Dr. Spilkia for some years now. Their location is top-notch and Dr. Spilkia will always come to give his professional opinion.

    Susan M.
  • Rating: 5 Dental Clinic in Philadelphia - Five Star Reviews by Joseph C.

    Staff is very nice, dentist is great. Facility is very clean and state of the art. Such a positive experience. I am very happy and highly recommend this office.

    Joseph C.
  • Rating: 5 Dental Clinic in Philadelphia - Five Star Reviews by S. Moody

    The best experience I have ever had at a dentist! No pain! Knowledgeable staff! Very gentle! Dr. Spilkia is the best cosmetic dentist in Philadelphia,PA!!

    S. Moody
  • Rating: 5 Dental Clinic in Philadelphia - Five Star Reviews by Clinton M.

    Once they say Cosmetic Dentist, this is actually the practice you need to visit. Dr. Spilkia is wonderful and the employees are very professional, useful, and walk out their method to make certain that you simply feel at ease! I'd certainly recommend this practice to anybody!

    Clinton M.
  • Rating: 5 Dental Clinic in Philadelphia - Five Star Reviews by Patti S.

    I went to Dr. David Spilkia for invisalign and it has been a great experience. He works very precisely, thoughtfully and his office is spotless. Highly professional, only uses clean new equipment, careful and thoughtful.... basically everything you'd wish your dentist to be! If you're looking for a cosmetic dentist in Philadelphia, PA - look no further!

    Patti S.
  • Rating: 5 Dental Clinic in Philadelphia - Five Star Reviews by M. Mccormick

    Dr. David Spilkia here in Philadelphia, PA has an amazing eye for detail. His work is tasteful, subtle, thorough, and customized. I wanted a perfect smile but I didn't want it to look fake or obvious. I'm so, so happy with everything, and I got that natural, straight smile I was hoping for. I like that his approach is smart, modern, personalized, and efficient. He knows exactly what he's doing and he's up on everything. He takes his time with me and gives me my best options. He's also just a super nice person. Can't recommend him highly enough - he's truly an awesome cosmetic dentist!! PS the view from his office is outstanding!!

    M. Mccormick
  • Rating: 5 Dental Clinic in Philadelphia - Five Star Reviews by A.Chandler

    When I came to Dr. David Spilkiaメs dental office here in Philadelphia, PA two days ago I discovered that visiting a dentist can be very pleasurable experience!!!! Honestly, Dr. Spilkia is the most professional and charming cosmetic dentist Iメve ever met in my life. The waiting time didn't exceed 15 min, the staff at David Spilkia, DMD was very professional and caring, and the overall office atmosphere was friendly and relaxing. Dr. Spilkia was just amazing - nice, funny, caring, patient, and super professional. I would definitely recommend him to all my friends!

    A.Chandler
  • Rating: 5 Dental Clinic in Philadelphia - Five Star Reviews by Brent P.

    Dr. David Spilkia and his staff always have the patient's interest in mind, which is a special quality in this city of Philadelphia. David Spilkia, DMD, is excellent at what they do and the passion is quite evident. I've been impressed with his knowledge of dentistry, his staying on the cutting edge of technology within the profession, and his attention to detail when it comes to giving the patients high-quality service. This dentist and his team are dedicated and obviously love their work and the people that seek out their expertise. Terrific office!

    Brent P.
  • Rating: 5 Dental Clinic in Philadelphia - Five Star Reviews by A. Mills

    I may be a little biased since Dr Spilkia is a close friend of mine; however he is the best dentist here in Philadelphia, PA I've ever had. I grew up with a phobia of dentists, but when he became a dentist many years ago, my fears quickly subsided thanks to his chair side manner. He has you feeling comfortable from the minute you step in. He is the only dentist I know of who actually phones you the day following major dental work to see how you're doing. Aside from being a great dentist, he really cares.

    A. Mills
  • Rating: 5 Dental Clinic in Philadelphia - Five Star Reviews by Doyle J.

    My entire family loves going to the dentist. Especially in a big city like Philadelphia, it can be stressful and confusing. Dr. Spilkia and his team are the best and SO gentle!

    Doyle J.
Dental Clinic in Philadelphia - Patient Video
Dental Clinic in Philadelphia - Dental Video
Dental Clinic in Philadelphia - Commercial Video
Dental Clinic in Philadelphia - Patient Reviews about Dr. David Spilkia
Hours of Operation
Monday :
8am-5pm
Tuesday :
9:30am-6:30pm
Wednesday :
8am-4pm
Thursday :
12noon-8pm
Friday :
By Special Appointment
Saturday :
(Alternate) 9am-2pm
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