NEW PATIENT INTAKE FORM

All information is confidential

Patient Information

Medic Alert*

The patient is an:*

Adult
Child

Title*

Date of birth*

Patient Name*

First Last

Prefer to be called

First

Legal Guardian's Name*

First Last

Address*

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

Home Phone*

Cell Phone*

Work Phone*

Preferred Phone*

Home
Cell
Work

Fax

Other Phone

Email*

Employer / School*

Occupation*

How did you hear about our office?*

Google
Patient

Whom may we thank for referring you to this office?*

First Last

Family Physician*

First Last

Phone*

Emergency Contact*

First Last

Relation*

Phone*

Person responsible for this account*

Self
Other

Name of person responsible for this account*

First Last

Relation*

Address*

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

Home Phone*

Work Phone*

Do you have dental insurance?*

Yes
No

Primary Insurance

Subscriber*

Relation*

Self
Spouse

Insurance Co*

Policy / Plan #*

Division / Sect. #*

Do you have secondary dental insurance?*

Yes
No

Secondary Insurance

Subscriber*

Date of Birth

Relation*

Self
Spouse

Insurance Co*

Policy / Plan #*

Division / Sect. #*

Step 1 of 4 - Patient Information

NEW PATIENT INTAKE FORM

Patient Information

Primary Insurance

Secondary Insurance

NEW PATIENT INTAKE FORM

Medical History

For Women Only

NEW PATIENT INTAKE FORM

Dental History

NEW PATIENT INTAKE FORM

Office Policy

Patient Release