New Patient Intake Form

Privacy note: This form collects health information. Host it on HTTPS and store submissions securely. If you need HIPAA-grade hosting/workflows, use a HIPAA-ready form system (example: a medical intake platform or a WordPress form plugin configured for HIPAA).

Patient Information

Date

SS# / HIC / Patient ID #

Last Name

First Name

Middle Initial

Address

E-mail

City

State

Zip

Sex

M F

Birthdate

Age

Marital Status

Partnered for years

Patient Employer / School

Occupation

Employer / School Address

Employer / School Phone

Spouse's Name

Spouse Birthdate

Spouse SS#

Spouse's Employer

Whom may we thank for referring you?

Dental Insurance

Who is responsible for this account?

Relationship to Patient

Insurance Co.

Group #

Is patient covered by additional insurance?

Yes No

If yes, fill out the secondary insurance below.

Subscriber's Name (Secondary)

Birthdate

SS#

Relationship to Patient

Insurance Co.

Group #

Dental History

Reason for today's visit

Former Dentist

City / State

Date of last dental visit

Date of last dental X-rays

Place a mark on “yes” or “no” to indicate if you have had any of the following:

How often do you floss?

How often do you brush?

Health History

Medications & Allergies

List any medications you are currently taking and the correlating diagnosis

Pharmacy Name

Pharmacy Phone

Allergies

Other (describe)

Phone Numbers

Home

Work

Ext

Cell Phone

Spouse's Work

Best time and place to reach you

In Case of Emergency (contact not in your household)

Name

Relationship

Home

Work

Update (for future appointment)

Has there been any change in your health since your last dental appointment?

Yes No

For what conditions?

Are you taking any new medications?

Agreements & Electronic Signature

Agreements included from the paper packet: (1) Insurance Assignment & Release (page 1), (2) Keep Appointments / Missed Appointment Policy (page 3), and (3) HIPAA Information and Consent acknowledgement (page 4).

I agree to the Insurance Assignment & Release. I understand and agree to follow the office appointment policy. I acknowledge the HIPAA Information and Consent terms.

Printed name of signer (patient/parent/guardian)

Relationship to patient (if not patient)

Draw your signature

By signing electronically, you intend your signature to be legally binding.