{practiceName}

New Patient Intake Form

Welcome to {practiceName}. To ensure we provide you with the best care, please take a moment to complete this intake form in detail. Your medical history is essential for us to understand your unique needs and customize our approach to your care. By filling out the following information accurately, you help us maintain the highest standard of dental service. Thank you for trusting us with your health!

Account ID*

Env

Practice Name*

Practice Recipient Email*

Patient Name*

First NameLast Name

Preferred Name

Date of Birth*

Date

Sex/Gender?*

Provincial Health Card No.

Height (inches)

Weight (pounds)

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

Phone Type*

MobileHomeWorkOther

Additional Phone Number

Area CodePhone Number

Phone Type

MobileHomeWorkOther

Contact E-mail*

example@example.com

Preferred Contact Method

School/Occupation

May we leave a voicemail regarding your appointment?*

YesNo

Are you likely to be available on short notice for future appointments or changes?*

YesNo

We would like to send you email and text communications which may include appointment confirmations, newsletters, upcoming events, and important notifications. Check the box if you would like to receive future emails and text communications from us.

Yes, I'd like to receive emails and texts

In case of emergency notify *

First NameLast Name

Relation *

Contact Phone Number*

Name of the Primary Care Provider (i.e. physician, nurse practitioner)

Primary Care Provider Phone Number

Primary Care Provider Address (street number and street name, city, province and postal code)

Name of Medical Specialist

Area of Specialty

Phone

Address of the Medical Specialist (street number and street name, city, province and postal code)

Name

First NameLast Name

Relation

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Work Phone

Occupation

Name

First NameLast Name

Relation

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Work Phone

Occupation

Please list any other people who may have access to this file

(e.g. scheduling appointments)

Name

First NameLast Name

Relation

How did you hear about us?*

Please provide name

Please explain further

Subscriber Name

Relationship to Patient

Subscriber Date of Birth

Date

Insurance CO

Policy Plan #

Division/Sect. #

Subscriber ID

If you have secondary insurance, please complete this section

Subscriber Name (Secondary)

Relationship to Patient

Subscriber Date of Birth

Date

Insurance CO

Policy Plan #

Division/Sect. #

Subscriber ID

1. Reason for dental visit:*

2. Do you have a dental problem that needs to be addressed as soon as possible?*

YesNo

3. Have you been visiting the dentist regularly?*

YesNo

Last dental visit

Date

X-rays

Date

Dental Hygiene Appointment

Date

4. How often do you brush your teeth per day?

5. How often do you floss your teeth per day?

6. Do your gums bleed regularly?

YesNo

7. Are your teeth sensitive to

8. Please check all that apply:*

Please list any other information that you feel we should have to provide you with the best dental care:

1. Do you have any health problems?*

YesNo

If yes, please provide details:*

2. Has there been any changes in your general health or weight in the past year?*

YesNo

If yes, please explain:*

3. Are you currently being treated for any medical condition or have you been treated in the last year?*

YesNo

If yes, please explain:*

4. When was the last time you had a medical examination?*

Were any problems identified?*

YesNo

If yes, please explain:*

5. Have you ever been hospitalized for any illnesses or operations?*

YesNo

If yes, please provide details:*

6. Are you taking any medications, non-prescription drugs, homeopathic or herbal supplements or hormones of any kind?*

YesNo

If yes, please list the name of the medication, dosage and reason for taking:*

Are you allergic to or have you had a reaction to any of the following items?

	Yes	No
Aspirin
Codeine
Darvon
Local Anesthetic
Nitrous Oxide

Calculation - Allergies

If you have any allergic other allergic conditions please list them below. This can include asthma, hay fever, food allergies, dental materials, injections or local anesthetic and metal or latex allergies.*

9. Do you have or have you ever had a replacement or a repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?*

YesNo

If yes, please explain:*

10. Do you routinely take pre-medication (e.g. antibiotics) prior to dental treatment?*

YesNo

If yes, please explain:*

11. Do you have a prosthetic or artificial joint?*

YesNo

If yes, please provide details:*

12. Do you have any conditions or have undergone therapies that could affect your immune system? (Leukemia, AIDS, HIV infection, radiation therapy, chemotherapy)*

YesNo

If yes, please provide details:*

13. Have you ever had hepatitis, jaundice, liver disease, or gastrointestinal disorders?*

YesNo

If yes, please provide details:*

14. Do you have a bleeding problem, bleeding disorder, bruising tendency, or have you had a blood transfusion?*

YesNo

If yes, please provide details:*

15. Do you have any or have you ever had any of the following ?*

	Yes	No
Fainting/Dizzy spells
Eating disorder
Stroke/TIA
Rheumatic fever
Mitral valve prolapse
Heart murmur
Asthma or Emphysema
Pacemaker
Lung disease
Tuberculosis
Cancer
Steroid therapy
Diabetes
Stomach ulcers
High blood pressure
Low blood pressure
Arthritis/Rheumatism
Seizures/Epilepsy
Kidney disease
Thyroid disease
Hyper/Hypoglycemia
Mental or Nervous disorder
Circulatory problems
Blood transfusion
Other communicable disease/Transmissible infection
Chest pain/Angina/Heart attack
Drug/Alcohol/Cannabis use or dependency
Shortness of breath
Osteoporosis

Calculation - Medical Conditions

If yes to any of the above, please provide details:

16.Do you have or have had any diseases not listed above?*

YesNo

If yes, please provide details:*

17. Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer, or heart disease)*

YesNo

If yes, please provide details:*

18. Do you smoke, vape, use e-cigarettes, chew tobacco, or consume cannabis products regularly?*

YesNo

If yes, please provide details:*

19. (For women only) Are you pregnant?

YesNo

If yes, what is the expected delivery date?*

Date

20.(For women only) Are you breastfeeding?

YesNo

21. Do you identify as a person with disability?*

YesNo

If yes, please explain:*

22. Have you recently travelled to areas where endemic diseases are present?*

YesNo

23. Have you recently experienced any new symptoms such as a cough, fever, chills, vomiting, diarrhea, rash or other illnesses since recent travel or otherwise?*

YesNo

24. Have you had a recent exposure to a communicable infectious disease? (e.g. measles, chicken pox or tuberculosis)*

YesNo

25. Have you recently received antimicrobial therapy? (antibiotics, antivirals, antifungals, antiparasitic)*

YesNo

If so, for what reason?*

26. Are your immunizations up to date?

YesNoPrefer not to answer

27. Is there any additional information related to your health that has not been addressed above? If so, please advise:

CHILDREN ONLY: Please list any medical conditions or illnesses the child has recently had. This can include measles, strep throat, tonsillitis

Your appointment time will be reserved for you. If you are unable to keep the appointment, we will require two business days' notice, otherwise it may be necessary to charge for the time lost. Check the box below to confirm your agreement with our office policy.*

I acknowledge that I need to give two business days' notice to reschedule or cancel my appointment. If I don't do so, I may be charged for the time lost.

Patient Privacy & Consent
We are committed to protecting the privacy of your personal information and using it responsibly. We collect personal, financial, and medical information as required to provide dental care and manage our services, in accordance with applicable laws.

Personal (Contact) Information such as your name, address, phone number, and email is collected and used to:

Create and update patient records
Process billing and insurance claims
Communicate appointment reminders and practice information

This information may be shared with insurance providers or third parties as required for payment and claims processing.

Financial Information is used solely for payment processing and is not shared without your consent, except where permitted by law for outstanding account collection.

Medical Information including health history and treatment details is collected to diagnose conditions and provide appropriate dental care. This information may be shared with:

Insurance providers for claims processing
Other healthcare professionals with your consent
Potential practice purchasers under strict confidentiality during a sale process

By signing below, you consent to the collection, use, and disclosure of your personal information as outlined above.

Treatment Consent
I hereby consent to the dental and oral surgery procedures that have been explained to me and deemed necessary or advisable by my dental care provider. This includes the administration of local anesthetics and any prescribed medications as required for my treatment.

I acknowledge and accept full financial responsibility for all fees associated with the procedures and treatments provided.

Financial Consent
Your dentist or certified specialist is obligated to treat you, not your dental plan. Treatment recommendations are based on your dental health needs, which may differ widely from what your plan covers. Base your decision on an informed discussion with our dental team regarding your dental needs as this decision can impact your health and should not be dictated by your dental plan coverage. Unless prior arrangements have been made, payment is due upon completion of treatment. Please note that not all services may be covered by your insurance carrier and every insurance plan has its own unique exceptions. It is the patient's responsibility to cover procedures that are not covered by the insurance plan. We look forward to taking care of your oral health needs and welcome you and your family to our team of dental professionals.

By signing this document, I confirm that all information I have provided is accurate to the best of my knowledge. I consent to the collection, use, and disclosure of my personal information as required for my care. I also consent to the recommended dental treatments and understand my financial responsibilities for all services provided.

Date*

Date

Signature*

{practiceName}

Patient Information

Emergency Contact

Primary Care Provider

Parent/Guardian/Caregiver 1 Information

Parent/Guardian/Caregiver 2 Information

Insurance Information

Patient Dental History

Medical History

Cancellation Policy

Authorization and Consent