New Dental Patient Intake | Preview

Dental Intake Form

Patient Information
Name*
First Middle Last
Date of Birth*
DD slash MM slash YYYY
Marital Status
Gender
Height (cm)
Weight (kg)
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone (Home)
Phone (Work)
Phone (Cell)
Email
Consent*
I consent to receiving regular emails regarding my oral health*
Consent*
I give you consent to leave a detailed message on my voicemail.*
Occupation
Employer
Family Physician
First Last
Dentist
First Last
Are you seeing a dental specialist other that us? (Ortho, perio, endo)
- Yes
- No
Name of specialist
Do you live alone?
- Yes
- No
Emergency contact
Name
First Last
Phone
For Prescription purposes
OHIP / RAMQ
Driver's License

What	How much	How often

Dental Intake Form