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Patient Information
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Contact
Patient Intake Form
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Patient Intake Form
Patient Information
Please Fill out form below / Por Favor, llene el formulario.
Today's Date
SS/HIC/Patient ID #
First Name
Last Name
Date of Birth
Sex
Male
Female
Marital Status
Married
Single
Separated
Divorced
Widowed
Minor
Spouse's Name
Spouse's Birthdate
Partnered for
Home Address
City
State
Zip Code
Email
Phone
Patient Employer or School Name
Employer or School Address
Employer or School Phone
Occupation
Dental Insurance
Who is responsible for this account?
Relationship to Patient
Insurance Co.
Group #
Is patient covered by additional insurance?
Yes
No
Subscriber's Name
Birthdate
Relationship to Patient
Insurance Co.
Group #
ASSIGNMENT AND RELEASE
Acceptance
I certify that I, and/or my dependents), currently hold insurance coverage specified by the provider listed below and assign all insurance benefits to the doctor named below, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on al insurance submissions.
The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Companyies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
Insurance Provider
Doctor / Provider
Signature of Patient, Parent, Guardian or Personal Representative
Today's Date
Relationship to Patient
Phone Numbers
Phone
Work
Ext
Spouse's Work Phone
Best time to reach you
Morning
Mid Day
Afternoon
Best Place to reach you
Work
Home
Mobile
Emergency Contact
Please specify someone who does not live in your household
Emergency Contact Name
Relationship
Phone
Work Phone
Dental History
Reason for today's visit
Former dentist
City
State
Date of last dental visit
Date of last Dental x-rays
Please select 'Yes' or 'No' to Indicate the following selections
Bad Breath
Yes
No
Bleeding Gums
Yes
No
Blisters on lips or mouth
Yes
No
Burning sensations on tongue
Yes
No
Chew on one side of mouth
Yes
No
Cigarette, pipe, or cigar smoking
Yes
No
Clicking or popping jaw
Yes
No
Dry mouth
Yes
No
Fingernail biting
Yes
No
Food collection between the teeth
Yes
No
Foreign Objects
Yes
No
Grinding Teeth
Yes
No
Gums swollen or tender
Yes
No
Jaw pain or tiredness
Yes
No
Lip or cheek biting
Yes
No
Loose teeth or broken fillings
Yes
No
Mouth breathing
Yes
No
Mouth pain, brushing
Yes
No
Orthodontic treatment
Yes
No
Pain around ear
Yes
No
Periodontal treatment
Yes
No
Sensitivity to cold
Yes
No
Sensitivity to heat
Yes
No
Sensitivity to sweets
Yes
No
Sensitivity when biting
Yes
No
Sores or growths in your mouth
Yes
No
How often do you floss?
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