{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 persons 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 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 Anaesthetic
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 anaesthetic 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 to 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 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 illness 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, antiparasitics)*

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.

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.

Date*

Date

Signature*

{practiceName}

Emergency Contact

Primary Care Provider

Parent/Guardian/Caregiver 1 Information

Parent/Guardian/Caregiver 2 Information

Insurance Information

Patient Dental History

Medical History

Cancellation Policy

Personal Information Patient Consent Form