dl-intake-03

New Patient Intake Form

New Patient Intake form version 03 is a simple two-step intake form for new dental patients. Users can fill out this form online from their own smart phone; a home computer; or in the clinic on a clinic tablet. The form requests patient information and also acts as a basic healthcare questionnaire. It includes OHIHP (The Ontario Health Insurance Plan) numbers and RAMQ (Régie de l’assurance maladie du Québec – administers the Québec Health Insurance Plan. Although this field is centric to Ontario and Quebec Canada the this form and other forms can be customized at request for other areas.

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