New Patient Intake Form
Patient Information
Patient Name:
Parent or Legal Guardian's Name:
Address:
Email:
Cell Phone:
Home Phone:
Work Phone:
Contact Preference:
Cell
Text
Home Phone
Work Phone
Email
How did you hear about our office?
Referral
Website
Signage
Coupon
Other
Referral Source:
Dental Concerns
Are you experiencing any dental problems or have any dental concerns?
Pain?
Constant
Occasional
None
Where?
Swelling? Where?
Medical History
Are you under the care of a physician?
Yes
No
Previous Dental Care
When was your last dental visit?
Are x-rays available?
Yes
No
Name of previous dentist:
Phone Number:
Address:
Insurance Information
Do you have a dental benefit plan?
Yes
No
Member ID Number:
Group Number:
Name of policy holder:
Policy holder's relationship to the patient:
Policy holder's birthdate:
Policy holder's employer:
Insurance company:
Insurance Company Address:
Phone number and/or insurance company website:
Appointment Information
Scheduled appointment date:
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