Dental Intake Form

Patient Information

Full Name

Marital Status

Gender

Address

City

State

Zip

SS No.

Date of Birth

Cell Phone No.

Work Phone No.

Email address

Place of Employment

Work Address

If Full-Time Student, School Name

Grade

Person responsible for the account? Minor Child - May need to complete both blocks for parent information adults - Complete primary insured dual coverage? also complete secondary insured

Patient (Self) Guardian Spouse Father Mother

Person to contact in case of emergency

Full Name

Address

City

State

Zip

Telephone No.

INSURANCE INFORMATION

Primary Insured

IF NO INSURANCE COMPLETE FOR THE RESPONSIBLE PARTY

Full Name

Address

City

State

Zip

Mobile Phone No.

Home Phone No.

Fax

Email address

Date of Birth

Relationship to Patient

Employer

Dental Ins. Co

SS No.

Subscriber No.

Group No.

Secondary Insured

Full Name

Address

City

State

Zip

Mobile Phone No.

Home Phone No.

Fax

Email address

Date of Birth

Relationship to Patient

Employer

Dental Ins. Co.

SS No.

`Group No.

Subscriber No.

Authorization

I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostic, photographic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the dental/medical histories are correct to the best of my knowledge. I grant the right to the dentist to release my dental / medical histories and other information about my dental treatment to third party payors and /or other health professionals.

Patient or Responsible Party

Payment in full at each appointment (cash or personal check)

Payment in full at each appointment

Visa

Mastercard

Other

Method of Payment

Responsible party currently has an account with this office

Yes No

If I do not pay the entire balance within

billing date, a service charge will be added to the account for the current monthly billing period.

The service charge will be a periodic rate

The service charge will be a periodic rate of per month (or a minimum charge of for a balance under which is an annual percentage rate of applied to the last month's balance.)

In the case of default of payment, I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorney fees incurred to effect collection of this account or future outstanding accounts.

Patient Name

Date

Primary reason for this dental appointment

Examination

Emergency

Consulation

Dental History

Do you have any specific dental problems?

Yes No

If yes, Please describe

Do you have dental examinations on a routine basis?

Yes No

Last Visit?

Do you think you have any active decay or gum disease?

Yes No

Do you brush and floss on a routine basis?

Yes No

If yes, Please describe

Do you like your smile?

Yes No

Why?

Does food catch between your teeth?

Yes No

Any loose teeth?

Yes No

Do you want to keep your remaining teeth?

Yes No

Do you edver have any clicking, popping or discomfort in the jaw joint?

Yes No

Do you brux or grind?

Yes No

Have your past experiences in a dental office always been postive?

Yes No

Do you smoke or chew?

Yes No

Any sores or growths in your mouth?

Yes No

Please discuss

Name of Previous Dentist (Optional)

Date of last full mouth x-rays (16 small films or panoramic)

Are you under a physician's care now?

Why?

Who?

Phone No.

(xxx) xxx-xxxx

Have you ever been hosptalized or had a major operation?

Yes No

Please discuss

Have you ever been had a serious injury to your head or neck?

Yes No

Please discuss

Are you taking any medications, pills or drugs?

Yes No

What?

Ever taken fen-phen?

Yes No

Are you on a special diet?

Yes No

Are you allergic to any medications or substances

Aspirin

Penicillin

Codeine

Acrylic

Metal

Latex Rubber

Other

Women

Pregnant? Trying to get Pregnant

Yes No

Nursing

Yes No

Taking Oral Contraceptives?

Yes No

Please discuss

Do you now have or have you ever had any of the following? Please check appropriate boxes.

Have you ever had any other serious illnesses not checked above?

Yes No

If yes please discuss

Do you wish to talk to the dentist privately about any problem?

Yes No

To the best of my knowledge, all preceding answers are correct. If I have any changes in my health status or if my medicines change I shall inform the staff and dentist at my next appointment without fail.

By typing your name below you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature

Date

MM/DD/YYYY

Reviewed By Doctor

Date

History Review and Significant Findings:

Medical Updates

I have read my MEDICAL HISTORY and confirm that it adequately states past and current conditions

Date

Exceptions

Patient Signature

Reviewed By

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