NEW PATIENT INTAKE FORM

Title

Mr.
Mrs.

Name*

First Last

Date of birth*

Do you reside in a care facility or are you hospitalized?*

Yes
No

Facility/Hospital Name*

Room

Unit

Address*

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

Phone*

Email

How did you hear about our clinic?

Internet search
Referral

Whom may we thank for the referral?

Contact Information

Do you handle your own finances?*

Yes
No

Financial Contact / POA

Name*

First Last

Relationship to Patient*

Address*

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

Phone*

Email*

Personal / Family Contact

Name

First Last

Relationship to Patient

Address

Street Address City Country

Phone

Email

Dental Information

Upper Denture*

Complete
Partial
None

Age*

Under 1 year old
1-5 years old
5-10 years old
Over 10 years old

Has the denture been relined?*

Under 1 year ago
1-5 years ago
5-10 years ago
Over 10 years ago
No, it has not been relined.

Lower Denture*

Complete
Partial
None

Age*

Under 1 year old
1-5 years old
5-10 years old
Over 10 years old

Has the denture been relined?*

Under 1 year ago
1-5 years ago
5-10 years ago
Over 10 years ago
No, it has not been relined.

Do you use denture adhesive?

Yes
No

Do you have any natural teeth remaining?

Upper teeth
Lower teeth
Upper & lower teeth

What is your current denture concern?*

Do you have a dentist?

Yes
No

Name

First Last

Phone

Date of last appointment

Under 1 year ago
1-5 years ago
5-10 years ago
Over 10 years ago

Is dental work needed?

Yes
No

Please explain what dental work is needed*

Dental Insurance Information

Do you have a dental plan?*

Yes
No

Company Name

Group / Policy #

Certificate / ID #

Are you a dependant?

Yes
No

Name of plan owner

First Last

Birthdate

Relationship

Do you have a secondary dental plan?*

Yes
No

Secondary Insurance Plan

Company Name

Group / Policy #

Certificate / ID #

Are you a dependant?

Yes
No

Name of plan owner

First Last

Birthdate

Relationship

Health Information

Cognitive:

Short Term Memory Loss
Difficulty Communicating
Difficulty Finding Words
Difficulty Reasoning
Difficulty Handling Tasks
Difficulty Following Instructions

Psychological:

Depression
Anxiety
Agitation
Paranoia
Hallucinations
Verbal Aggression
Physical Aggression

Medical Conditions:

Have you had a stroke?*

Yes
No

How long ago?*

Under 1 year ago
1-5 years ago
5-10 years ago
over 10 years ago

Did it cause any paralysis that is still apparent?*

Yes
No

Check all that apply:*

Facial droop
Speech impaired
Arm/hand paralysis
Other

Please describe:*

Other Health Concerns:

Weight Loss
Hearing Loss
Dry Mouth
Excessive Saliva
Swallowing Issues
Problems Chewing
Food Minced
Food Pureed

Explain any health conditions as needed:

Do you use a wheel chair?

Yes
No

Do you use a walker?

Yes
No

Is extra assistance required?

Yes
No

Please explain what assistance may be required

Do you have a physician?

Yes
No

Name

First Last

Phone

Consent

By signing this Consent you agree to have provided this personal information. This information has been collected for the following purposes:

To diagnose and provide safe and efficient health care
To assess your denture needs and advise you of your treatment options
To communicate with you and your other health care professionals
For scheduling appointments, billing purposes, including dental insurance forms

Name of person filling out this form*

First Last

Relationship*

Patient
Financial Contact/POA
Personal/Family Contact

Please Enter Your Signature*

Comments

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