NEW PATIENT INTAKE FORM

Patient Information

Questions marked with a* are required. Questions you are unsure of or would prefer to answer verbally can be skipped.

Patient Name(Required)

First Last

Date of birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Who should we contact in case of emergency?(Required)

First Last

Relationship(Required)

Phone(Required)

Do you have dental insurance?(Required)

Yes

No

Primary Insurer

Insurance company name

Certificate / ID number

Group / policy number

Are you a dependant?

Yes

No

Name of insurer

Insurer date of birth

Relationship

Secondary insurer

Insurance company name

Certificate / ID number

Group / policy number

Are you a dependant?

Yes

No

Name of insurer

Insurer date of birth

Relationship

How did you hear about our clinic?(Required)

Internet search

Social media

Referral

Newspaper or print ad

Sign

Other

Please specify:

NEW PATIENT INTAKE FORM

Consent

Consent(Required)

I, the undersigned, certify that all the medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted any information. I consent to my Dentist, previous Denturist or Physician being contacted if necessary, as further dental/medical information may be required for my dental care. I, the undersigned, hereby consent to the performing of the preventative dental procedures. I, the undersigned, am aware that the whole amount of treatment is due to be paid by me and understand any direct billing to my insurance plan that comes back unpaid is to be paid promptly by me.(Required)

Patient signature(Required)

Name

This field is for validation purposes and should be left unchanged.

NEW PATIENT INTAKE FORM

Patient Information

Primary Insurer

Secondary insurer

NEW PATIENT INTAKE FORM

Medical history

NEW PATIENT INTAKE FORM

Denture History

NEW PATIENT INTAKE FORM

Consent