• {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!

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  • Emergency Contact

  • Primary Care Provider

  • Parent/Guardian/Caregiver 1 Information

  • Parent/Guardian/Caregiver 2 Information

    (If different than above)
  • Please list any other persons who may have access to this file

    (e.g. scheduling appointments)

  • Insurance Information

    If the patient has a dental plan, please complete the following:
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  • If you have secondary insurance, please complete this section

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  • Patient Dental History

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  • Medical History

    Please select yes or no to each question.
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  • 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.
  • Personal Information Patient Consent Form

  • We are committed to protecting the privacy of our patients' personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances described in this form, we also collect, use and disclose personal information when permitted or required by law.

    We collect information from our patients such as names, home addresses, work addresses, home telephone numbers, work telephone numbers, and e-mail addresses. (Collectively referred to us "Contact Information"). Contact Information is collected and used for the following purposes:

    • To open and update patient files.
    • To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts.
    • To process claims for payment or reimbursement from third-party health benefit providers and insurance companies.
    • To send reminders to the patients concerning the need for further dental examination or treatment.
    • To send patients informational material about our dental practice.

    Contact Information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for
    reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient's behalf.

    Financial information is collected for payment processing purposes. it is not shared with third parties without your consent, unless permitted by law for
    outstanding bill collection purposes.

    We collect information from our patients about their health history, their family health history, physical condition and dental treatments. (Collectively
    referred to us "Medical Information") Patients' Medical Information is collected and used for the purpose of diagnosing dental conditions and providing
    dental treatment.

    Patients' Medical Information is disclosed:

    • To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all
      or part of the cost of dental treatment or has asked us to submit a claim on the patient's behalf.
    • With the consent of the patient, to other dentists and dental specialists, or to other health care professionals.
    • If we are ever considering selling all or part of our dental practice, qualified potential purchasers may be granted access as part of the due
      diligence process to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information.
  • By signing this document, I confirm that all answers I have given above are true to the best of my knowledge and I consent to the collection, use and disclosure of my personal information as set out above.

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