123Dentist New Patient Health History

{practiceName}

New Patient Health History Form

Welcome to {practiceName}. In order to provide you with the best possible care, we kindly ask you to complete this intake form thoroughly. Your medical history is a crucial component of your healthcare journey, aiding our team in understanding your unique needs and tailoring our approach accordingly. Please take the time to fill out the following information accurately and comprehensively. Your cooperation ensures that we can offer you the highest standard of dental care. Thank you for entrusting us with your health.
Account ID*
Env*
Practice Name*
Practice Recipient Email*
example@example.com
Patient Name*

First NameLast Name
Preferred Name (if different from above)
Address*

Address

Street Address Line 2

CityProvince/ State

Postal / Zip CodeCountry
Date of Birth*

MonthDayYear
Gender
Provincial Health Card Number
Preferred Phone*

Area CodePhone Number
Phone Type*
Email*
example@example.com
Emergency Contact Name*
Emergency Relation*
Emergency Phone No. *

Area CodePhone Number
Referred by*
Please provide name*
Please explain further*
INSURANCE INFORMATION

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

MonthDayYear
Date
Insurance Company
Policy Description
Policy Number
Policy/Subscriber ID
Division/Section #
SECONDARY INSURANCE
Subscriber Name
Relationship to Patient
Subscriber Date of Birth

MonthDayYear
Date
Insurance Company
Policy Description
Policy Number
Policy/Subscriber ID
Division/Section #
In the following sections, please select whichever applies. Your answers are for purposes of your treatment only and will be kept confidential in accordance with applicable laws.
DENTAL HISTORY
Please enter your previous Dentist name and Location*

Please review the following questions.*

	Yes	No
Do your gums bleed while brushing or flossing?
Are your teeth sensitive to cold, hot, sweets, or pressure?
Have you ever had difficulty opening or closing jaw?
Have you had any pain in your jaw area?
Do you have any sores or lumps in or near your mouth?
Have you ever had a head, neck or jaw injury?
Are you happy with the appearance of your teeth?
Do you ever feel nervous about visiting the Dentist?
Do you have any other concerns about having Dental Treatment?

If you answered yes to any of the questions above, please provide further details.*
Date of your last cleaning

MonthDayYear
Date
Date of your last Dental X-ray

MonthDayYear
Date
MEDICAL INFORMATION
Are you currently seeing a Family physician?*

YesNo
Please enter name, phone number and date of last visit*
Have you recently (in the last 2 years) been hospitalized or had a major operation?*

YesNo
Please explain*
Have you ever had a serious head or neck injury?*

YesNo
Please explain*

Please review the following section and indicate all that apply. Please note that during your initial visit, you may be asked some questions about your responses to this questionnaire and there may be additional questions regarding your health.*

	Yes	No
AIDS/HIV Positive
Alzheimer's Disease
Anaphylaxis
Anemia
Anorexia
Arthritis/Gout
Artificial Heart Valve
Artificial/Prosthetic Joint(s)
Asthma
Blood Disease
Blood Disorders: Bleeding/Bruising Tendency
Bulimia
Cancer/Radiation/Chemotherapy
Circulation Problems
Diabetes
Emphysema
Epilepsy/Seizures
Fainting
Gastrointestinal Disorders
Glaucoma
Heart Attack/Failure
Heart Disease
Heart Murmur
Heart Pace Maker
Heart Surgery
Hemophilia
Hepatitis A/B/C
High Blood Pressure
Infective Endocarditis
Jaundice
Kidney Disease
Leukemias
Liver Disease
Lung Disease
Organ/Medical Transplant
Psychiatric/Mental/Nervous Disorder
Sickle Cell Disease
Stroke
Tuberculosis

Calculation - Medical Conditions
If you answered yes to any of the questions above, please provide further details.*
MEDICATIONS: Are you currently taking or have recently taken any medication or non medication medicine?*

YesNo
MEDICATIONS: Please list, including dosage.*

ALLERGIES: Are you allergic to or have you had a reaction to any of the following:*

	Yes	No	N/A
Barbiturates, sedatives, or sleeping pills
Antibiotics
Aspirin
Codeine
Local Anesthetic
Nitrous Oxide
Latex

Calculation - Allergies
If you answered yes to any of the questions above, please provide further details.*
Other allergies
WOMEN ONLY: Are you taking oral birth control pills?*

YesNoN/A
WOMEN ONLY: Are you, or could you be pregnant?*

YesNoN/A
What is your expected delivery date?*

MonthDayYear
Date

CHILDREN ONLY: Please list conditions or illnesses your child has had recently:

	Yes	No	N/A
Chicken Pox
Measles
Strep throat
Tonsillitis

Calculation - Children conditions
SUBSTANCE USE
Do you use any form of Tobacco and/ or are wearing a Nicotine patch?

YesNo
How often?
Do you consume alcohol?

YesNo
How often?
Do you use any form of cannabis and/or cannabinoids?

YesNo
How often?
Would you consider yourself to be dependent on alcohol or drugs?

YesNo
Would you like to discuss any of the following with us at your initial appointment? (Check all that apply)

VeneersGummy SmileWhite FillingsOral Conscious SedationTotal Smile MakeoversReplace Metal fillingsReplace Missing TeethCorrect Mislaligned TeethCosmetic DenturesSleep Apnea/SnoringBroken/Cracked TeethDental ImplantsEliminate GapsClear Aligner TherapyIn-Office Teeth WhiteningRejuvenate Worn/ Stained TeethRoutine Dental Hygiene and Overall Oral Health
Add any additional information you would like us to know.
OFFICE POLICIES
To keep our standard of care to a level that best serves your dental needs and the needs of others, we ask you to please observe the following guidelines:

CANCELLATION POLICY:
There are many times when our patients require urgent or emergency treatment and therefore require an appointment as soon as possible. When patients give the clinic advanced notice of their need to cancel a scheduled appointment, this time can, in turn, be allocated to these patients in need of urgent treatment. In this way, the clinic can best serve the needs of ALL patients. Bearing these special needs in mind, the clinic requires a minimum of 2 business days' notice if an appointment must be cancelled. If less than 2 business days' notice is given to cancel an appointment, a cancellation fee will be applied. Please note that insurance companies do not cover fees for broken appointments, therefore payment is the patient's responsibility.

PAYMENT POLICY:
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 "quirks" and 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.
PERSONAL INFORMATION PATIENT CONSENT
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.
The following section is to be completed by the patient.

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.

I have read and understood the above policies of {practiceName} and understand my responsibilities as a patient.
Date

MonthDayYear
Date
Patient Signature*

Clear
Should be Empty:

INSURANCE INFORMATION

DENTAL HISTORY

MEDICAL INFORMATION

SUBSTANCE USE

OFFICE POLICIES

PERSONAL INFORMATION PATIENT CONSENT