New Patient Intake Form

New Patient Intake Form
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

Last NameFirst NameInitial
SSN
Why we are required to collect your social security number?

Like all health care providers, we require your social security number to insure proper billing, treatment, access, and cataloging of your medical records.
Signature

Clear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Sex

MaleFemale
Age
Birth Date

MonthDayYear
Date
Marital status

SingleMarriedWidowedSeparatedDivorced
Patient Employed By
Occupation
Business Address
Business Phone
Please enter a valid phone number.
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

Last NameFirst NameInitial
Relation to Patient
Birth Date

MonthDayYear
Date
SSN
Why we are required to collect your social security number?

Like all health care providers, we require your social security number to insure proper billing, treatment, access, and cataloging of your medical records.
Signature

Clear
Address(if different from patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Person Responsible Employed By
Occupation
Business Address
Business Phone
Please enter a valid phone number.
Business Email
example@example.com
Insurance Company
Phone
Please enter a valid phone number.
Insurance Address
Contract #
Group #
Subscriber#
Name of other dependents under this plan
Pharmacy
Phone
Please enter a valid phone number.

Additional Insurance
Is patient covered by additional insurance?

YesNo
Subscriber Name
Relation to Patient
Birth Date

MonthDayYear
Date
SSN
Why we are required to collect your social security number?

Like all health care providers, we require your social security number to insure proper billing, treatment, access, and cataloging of your medical records.
Signature

Clear
Address(if different from patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
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 Address
Contract #
Group #
Subscriber#
Name of other dependents under this plan

Authorization
I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist.

I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.

I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.
Signature

Clear
Date

MonthDayYear
Date
Payment is due in fun at time of treatment, unless prior arrangements have been approved.
Should be Empty:

Patient Information