CA New Patient Intake Form (long)

{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 Information
Patient Name*

First NameLast Name
Preferred Name
Date of Birth*

MonthDayYear
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*
Format: (000) 000-0000.
Phone Type*

MobileHomeWorkOther
Additional Phone Number
Format: (000) 000-0000.
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
Emergency Contact
In case of emergency notify *

First NameLast Name
Relation *
Contact Phone Number*
Format: (000) 000-0000.
Primary Care Provider
Name of the Primary Care Provider (i.e. physician, nurse practitioner)
Primary Care Provider Phone Number
Format: (000) 000-0000.
Primary Care Provider Address (street number and street name, city, province and postal code)
Name of Medical Specialist
Area of Specialty
Phone
Format: (000) 000-0000.
Address of the Medical Specialist (street number and street name, city, province and postal code)
Parent/Guardian/Caregiver 1 Information
Name

First NameLast Name
Relation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Occupation
Parent/Guardian/Caregiver 2 Information

(If different than above)
Name

First NameLast Name
Relation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
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
Insurance Information

If the patient has a dental plan, please complete the following:
Subscriber Name
Relationship to Patient
Subscriber Date of Birth

MonthDayYear
Date
Insurance Company
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

MonthDayYear
Date
Insurance CO
Policy Plan #
Division/Sect. #
Subscriber ID
Patient Dental History
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

MonthDayYear
Date
X-rays

MonthDayYear
Date
Dental Hygiene Appointment

MonthDayYear
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

HotColdBitingSweetsSourOther
8. Please check all that apply:*

Do you feel any pain in your teeth?Have you ever had any head, neck or jaw injuries/surgery?Do you have dry mouth or difficulty swallowing?Do you snore or have sleep apnea?Does your jaw crack, click or pop when opened widely?Do you bite your lips/cheeks frequently?Have you ever experienced any growths, lumps or sore spots in your mouth?Have you noticed any loosening/movement of your teeth?Have you had periodontal (gum) treatment?Have you had orthodontic (braces) treatment?Have you had previously problems with dental treatment?Are you satisfied with the appearance of your teeth?Are you nervous/anxious/fearful during dental treatment?None of the above
Please list any other information that you feel we should have to provide you with the best dental care:
Medical History

Please select yes or no to each question.
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?

Rows	Yes	No
Aspirin
Codeine
Local Anesthetic
Nitrous Oxide
Latex

Calculation - Allergies
Do you have any additional allergies or other allergic conditions?*

YesNo
Please list any allergies or other allergic conditions below. This can include asthma, hay fever, food allergies, dental materials, injections, local anesthetic or metal 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 ?*

Rows	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?*

MonthDayYear
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
Cancellation Policy

Please know that appointment times have been reserved especially for you, and any change in the schedule affects many people. If for any reason you are unable to keep the reserved appointment time, we ask the courtesy of two business days' notice to allow us to offer the time to another client who may be waiting for an opening. Appointments cancelled with less than two business days' notice may be subject to a broken appointment fee; amount of the fees is dependent on the length of the appointment.
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.
Authorization and Consent
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*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

{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