Patient Intake Form

Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely. If you have any questions or need assistance, please ask us - we will be happy to help.

Patient Information (CONFIDENTIAL)

Patient #

SS#/SIN*

Date

Patient's Sex

F

M

Name*

Birthdate*

Home Phone

Address*

City*

State/Prov.*

Zip/P.C.*

Email*

Cell Phone*

Do you prefer to receive your calls at your:

Home

Work

Cell Phone

Check Appropriate Box:

If Student, name of School/College

City

State/Prov.

Student Type

Full-Time

Part-Time

Patient or Parent/Guardian's Employer

Work Phone

Business Address

City

State/Prov.

Zip/P.C.

Spouse or Parent/Guardian's Name

Employer

Work Phone

Whom may we thank for referring you?

Person to contact in case of emergency

Phone

Responsible Party

Name of Person Responsible for this Account

Relationship to Patient

Address

Home Phone

Email

Cell Phone

Driver's License #

Birthdate

Financial Institution

Employer

Work Phone

SS#/SIN

Is this person currently a patient in our office?

Yes

No

For your convenience, we offer the following methods of payment. Please select the option you prefer. Payment in full at each appointment.

Cash

Personal Check

VISA

MasterCard

I wish to discuss the office's payment policy

Insurance Information

Do You Have Insurance?*

Yes

No

Name of Insured*

Relationship to Patient

Birthdate*

SS#/SIN*

Date Employed

Name of Employer*

Union or Local #

Work Phone

Address of Employer

City

State/Prov.

Zip/P.C.

Insurance Company*

Group #

Policy/ID #*

Ins. Co. Address

City

State/Prov.

Zip/P.C.

How much is your deductible?

How much have you used?

Max. annual benefit?

Do you have any additional insurance?*

Yes

No

If Yes, Complete the Following:

Name of Insured*

Relationship to Patient

Birthdate*

SS#/SSIN*

Date Employed

Name of Employer*

Union or Local #

Work Phone

Address of Employer

City

State/Prov.

Zip/P.C.

Insurance Company*

Group #

Policy/ID#*

Ins. Co. Address:

City:

State/Prov.

Zip/P.C.

How much is your deductible?

How much have you used?

Max. annual benefit?

Authorization and Release

Payment is due in full at the time of treatment unless prior arrangement have been approved.

This office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductible that my insurance does not cover. I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence, and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent.

Signature of patient (or parent/guardian if minor)*

Date*

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Patient Intake Form

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