New Patient Intake Form
Welcome
We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we'll be glad to help you. We look forward to working with you in maintaining your dental health
Patient Information
Name
*
First Name
Initial
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security #
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Sex
*
Male
Female
Birthdate
*
-
Month
-
Day
Year
Date
Marital Status
*
Single
Married
Widowed
Separated
Divorced
Patient Employed by
Occupation
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Phone
Please enter a valid phone number.
Business Email
example@example.com
Whom may we thank for referring you?
Notify in case of emergency
*
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Business Phone
Please enter a valid phone number.
Email
example@example.com
Primary Insurance
Person Responsible for Account (if different from patient)
First Name
Initial
Last Name
Relation to Patient (if different from patient)
Birthdate (if different from patient)
-
Month
-
Day
Year
Date
Address (if different from patient)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone (if different from patient)
Please enter a valid phone number.
Cell Phone (if different from patient)
Please enter a valid phone number.
Email (if different from patient)
example@example.com
Social Security # (if different from patient)
Person Responsible Employed by (if different from patient)
Occupation (if different from patient)
Business Address (if different from patient)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Phone (if different from patient)
Please enter a valid phone number.
Business Email (if different from patient)
example@example.com
Insurance Company
Phone
Please enter a valid phone number.
Insurance Email
example@example.com
Group #
Subscriber #
Name of other dependents under this plan
Is patient covered by additional insurance?
Yes
No
Additional Insurance
Subscriber Name
First Name
Initial
Last Name
Relation to Patient
Birthdate
-
Month
-
Day
Year
Date
Address (if different from patient)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Social Security #
Subscriber Employed by
Business Phone
Please enter a valid phone number.
Business Email
example@example.com
Insurance Company
Phone
Please enter a valid phone number.
Insurance Email
example@example.com
Group #
Subscriber #
Name of other dependents under this plan
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: