(Campbell) New Patient Intake Form

New Patient Intake Form

So we can ensure that we can provide you with the best care possible, please fill out the following private and secure HIPAA compliant form to the best of your abilities. Please contact our office if you would prefer a paper form.
Patient Information
Full Name*

PrefixFirst NameMiddle NameLast Name
Preferred Name
Date of Birth*

DayMonthYear
Gender Assigned at Birth*
Gender Identity
Occupation
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
This is my:*
Phone Number*
This is my:
Phone Number
E-mail*
Welcome to our Practice
How did you hear about our practice?*
Who can we thank for referring you to our practice?
Dental Benefit Information

You can leave this section blank if you have already provided us this information.
Subscriber's Name
Subscriber's Date of Birth
Name of Plan Carrier
Relationship of patient to subscriber
Member ID or SSN#
Group #
Employer Name
Phone Number for Dental Plan/Carrier
In case of Emergency
Emergency Contact Name*
Phone Number*
General Practitioner Name
Phone Number
Name of Medical Center
Are you being treated by your GP or a Specialist at the moment?*

YesNo
If yes, please give details
Your Medical History
Please tick to indicate that you have had the following conditions*

Alzheimers/DementiaAnxietyArthiritisArtificial Heart ValveArtificial jointsAsthmaAtrial fibrillationLung Disorders/DiseaseCancerCerebral palsyChemotherapyChronic PainColitisCrohn's diseaseDepressionDiabetesDysrhythmiaEmphysemaEpilepsy/SeizuresEye ProblemsFatigueFibromyalgiaGastoparesisGERD/Acid RefluxGlaucomaHay FeverHeart (Surgery, Disease, Attacks)Heart DiseaseHeart MurmurHepatitisHerpesHIVHypercholesterolemia- High cholesterolHyperlipidemia- High fat in bloodHypertension-High Blood Pressure HBPHypothyroidism-underactive thyroidHyperthyroidism-overactive thyroidHypotension- Low Blood PressureJoint ReplacementKidney ProblemsLiver DiseaseMesotheliomaMigrainesMitral valve prolapseMultiple SclerosisNasal Obstruction/Deviated SeptumOsteoporosisPacemakerParkinson's diseasePsychiatric/Psychological CareRadiation TherapyRheumatoid autoimmune diseaseSexually Transmitted DiseaseSleep ApneaStrokeTrigeminal neuralgia painOther
Do you have any other medical conditions not listed above?*

YesNo
If yes, please give details
Do you smoke cigarettes?*

YesNo
Do you smoke marijuana?*

YesNo
Do you enjoy other recreational drugs?*

YesNo
If yes, please give details
Has your GP or Specialist told you that you require taking antibiotics before dental treatment?*

YesNo
Are you pregnant?

YesNo
If yes, how many weeks?
Do you have any allergies to

AcetaminophenAmoxicillin/PenicillinAspirinClindamycinCodeineErythromycinIbuprofenLatexLocal AnestheticMintMetalSulfaOther
Do you have any adverse reactions and/or allergies to any drugs or medications not listed above?*

YesNo
If yes, please give details
Are you taking any drugs or medications (including vitamins & herb supplements)?*

YesNo
If yes, please write down the name of the medication and reason for taking it. For example: "Insulin for Diabetes". (If you have a large list, you can upload a document or take a photo of your list on your phone below and submit it)
Upload a photo or document of your medication list

Upload a File

Cancelof
Take a photo of your medication list on your phone
Your Dental History
Reason for your dental visit*
Please mark if any of the following is relevant to you

Previous bad experience at the dentistJaw clicks or hurtI feel that I grind my teethI've had orthodontic (braces) treatmentI wear a night guardI've had periodontal (gum) treatment or deep cleaningMy gums bleed when I brush my teeth or flossI believe I have bad breathI have teeth sensitive to hot/coldOther issues
Is there any other concerns about your teeth? If yes, please give details.
Are you interested to see if we could offer any cosmetic procedures to your teeth?

YesNoUnsure
If yes, which procedures are you particularly interested in?
How long since your last dental appointment?*
How often do you have dental examinations?
Have you had any dental x-rays in the past year? Our office requires new dental x-rays be taken if your most recent x-rays are over 1 year old.*

YesNoUnsure
Preferred Reminder Method
What is your preferred reminder method, when confirming your appointments?*

TelephoneEmailText
What is your preferred reminder method, when reminding your about your 6 monthly dental examinations & cleans?*

TelephoneEmailText
Privacy & Confidential Information
I have confidential medical information that I do not wish to write down. I would prefer to speak to the dentist about this.*

YesNo
I have read the Privacy Policy and understood the policy.*

YesNo
Terms & Conditions
Consent for Treatment:
1. I hereby authorize the dentist or designated staff to take x-rays, study models, photographs and other diagnotic aids deemed appropriate by the dentist to make a thorough diagnosis as mutually agree upon by me.
2. Upon such diagnosis, I authorize the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide the appropriate care.
3. I agree to be responsible for payment of all services rendered on my behalf and/or on behalf of my dependants. I understand that payment is due at anytime of service unless other arrangements have been made.
Payment for Treatment:

We accept Visa, Mastercard, American Express, personal cheque and cash.

We also can process your private health fund claim at the time of your appointment but need your card at every visit.

Cancellation Policy:

We have a 48 hour (2 business day) cancellation policy to allow us ample time to offer your appointment to another patient in need of it. A fee may be charged for missed appointments or failure to reschedule before the 48 hour time limit.

I understand the consent for treatment, the payment and cancellation policies as stated above.

By my electronic signature below, I agree to the terms and conditions.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health and I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form. It is my responsibility to inform the dental office of any changes in medical status.
Signature*

Clear
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Relationship to Patient*
Name of signee if other than patient
Patient Photo
One of the patient identifiers for the National Standard is a patient photo.

If you have a preferred photo you would like to use, please upload or take a photo of yourself on your phone for your patient file.
Upload a photo of yourself for your patient file

Upload a File

Cancelof
Take a photo of yourself for your patient file
Should be Empty:

Patient Information

Welcome to our Practice

Dental Benefit Information

In case of Emergency

Your Medical History

Your Dental History

Preferred Reminder Method

Privacy & Confidential Information

Terms & Conditions

Patient Photo