1st Class Dentures
Step
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- Patient Information
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NEW PATIENT INTAKE FORM
Patient Information
Patient name
*
First
Last
Date of birth
YYYY slash MM slash DD
Phone
Receive text communications
*
Yes
No
Email
*
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Emergency contact
First
Last
Relationship
Phone
Physician's name
First
Last
Dentist's name
First
Last
Dental Insurance Information (Primary)
Insurance company name
Primary subscriber
Subscriber date of birth
YYYY slash MM slash DD
Employer
Occupation
Work Phone
Subscriber ID#
Group ID#
Dental Insurance Information (Secondary)
Insurance company name
Primary subscriber
Subscriber date of birth
YYYY slash MM slash DD
Employer
Occupation
Work Phone
Subscriber ID#
Group ID#
Direct Payment Consent
I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the named denturist or dental entity.
NEW PATIENT INTAKE FORM
Medical history
Do you have regular dental checkups?
Yes
No
When was your last dental exam:
Have you ever had injuries to your face or jaw?
Yes
No
Do your jaws “pop” or “lock” when opening your mouth wide?
Yes
No
Do you have dry mouth?
Yes
No
Do you wear Dentures/Partials?
Yes
No
How old are they?
Do you sleep with your denture?
Yes
No
Current Dental Issues
Pain
Aesthetics
Poor chewing capabilities
Nervous
Failing / broken teeth
Denture looseness
Other
Other details
Smile Wish List
I would like my teeth whiter
I would like my teeth to look natural
I want my dentures tighter
I want to be able to eat anything
I want to be confident
Other
Other details
What would be the most important to you about your future teeth?
Do you have or have you had any of the following?
High Blood Pressure
Low Blood Pressure
Stomach Troubles / Ulcers
Epilepsy / Seizures
Fainting / Dizzy Spells
Asthma
Stroke
Diabetes
Respiratory Disease
Tuberculosis
AIDS or HIV infection
Radiation Therapy Head/Neck
Heart Disease / Attack
Recent Weight Loss
Cardiac Pacemaker
Cancer
Repeat Headaches
Arthritis
Hepatitis
Herpes
Others not listed
Please list all the medications you are taking:
Please list any allergies:
Please list any vitamins you are taking:
Are you allergic to Latex?
Yes
No
Do you smoke or use tobacco?
Yes
No
NEW PATIENT INTAKE FORM
Consent
How did you hear about our office?
TV: MeTV
TV: Fox
TV: ABC
Internet: Google
Internet: Bing
Internet: Facebook
Internet: Yelp
Friend / Family
Radio
Dentist
Other
Consent
*
I fully understand that I am using the services of a Denturist, not a dentist. I understand that a Denturist does not diagnose, evaluate or treat any diseases or malfunctions of the oral cavity and I should see a dentist or physician if such services are required.
*
Signature
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Phone
This field is for validation purposes and should be left unchanged.
1st Class Dentures
6051 N Eagle Rd
Boise, ID 83713
208-336-8873
[email protected]