NEW PATIENT INTAKE FORM

NEW PATIENT INTAKE FORM
Questions marked with a * are required. Questions you are unsure of or would prefer to answer verbally can be skipped.
Patient information
Name *

First Name Last Name
Date of birth

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone *

Area Code Phone Number
Email *
example@example.com
Do you have dental insurance? *

Yes No
Dental insurance information
Provide name of insurer & policy account number.
How did you hear about our clinic?

Internet search Social media Referral Newspaper or print ad Sign
Medical history
Do you have a family physician? *

Yes No
Do you have a dentist? *

Yes No
Do you experience any dry mouth with or without medication? *

Yes No
Have you ever had any head, facial, jaw or neck trauma? *

Yes No
Do any of the following conditions apply to you?

Facial muscle tenderness Joint clicking, popping or locking Migraines or headaches Earaches TMJ (Jaw) pain Neck or shoulder pain Hearing issues Lumps or sores in your mouth now Burning sensation on your lips or tongue Do you grind your teeth Sore or tender gums Do you snore a lot Do you gasp or stop breathing in your sleep
Additional condition details
Do you smoke? *

Yes No
Are you allergic to the following?

Latex Metal Acrylic
Have you ever had or are going through radiation or chemotherapy? *

Yes No
When did you last go through radiation or chemotheraphy?

Month Day Year
Date
Do you have hearing or memory issues where you may need extra assistance? *

Yes No
Do you have any of the following serious illnesses?

Heart condition High blood pressure Hepatitus A/B/C Drug addiction Cold sores Mouth cancer HIV or AIDS Epilepsy or seizures Tuberculosis Diabetes Stroke Jaundice Asthma Sinus trouble Snoring
If you have a serious illness that is not listed, please list
Is there anything else the denturists should know about your health?
Denture history
Do you have a complete denture? *

Upper denture Lower denture None
Upper denture: Age
Upper Denture: Last Reline
Lower denture: Age
Lower denture: Last Reline
Do you have partial dentures? *

Upper denture Lower denture None
Upper denture: Age
Lower denture: Age
Do you have implants?

Yes No
Do you have any natural teeth remaining? *

Upper Lower None
When was the last time you have seen a dentist?
Do you know if you need any dental work done? ( ie. cleaning, fillings, extractions)

Yes No Not Sure
Are you happy with your current dentures?

Yes No Somewhat
What are your concerns with your current dentures?
What is your goal with your dentures?
Consent
I, the undersigned, certify that all the medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted any information. I consent to my Dentist, previous Denturist or Physician being contacted if necessary, as further dental/medical information may be required for my dental care. I, the undersigned, hereby consent to the performing of the preventative dental procedures. I, the undersigned, am aware that the whole amount of treatment is due to be paid by me and understand any direct billing to my insurance plan that comes back unpaid is to be paid promptly by me.
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

NEW PATIENT INTAKE FORM

Patient information

Medical history

Denture history

Consent