New Patient Intake Form

FOR OFFICE USE ONLY:

Date:

Patient Name:

Parent or Legal Guardian’s Name:

Address:

Email:

Cell Phone: Home Phone: Work Phone:

Contact Preference: Cell Text Home Phone Work phone Email

How did you hear about our office? Referral Website Signage Coupon

Other

Referral Source:

Are you experiencing any dental problems or have any dental concerns?

Pain? Constant Occasional Where?

Swelling? Where?

Are you under the care of a physician? Yes No

When was your last dental visit? Are x-rays available?

Name of previous dentist: Phone Number:

Address:

Do you have a dental benefit plan? Yes No

If Yes:

Member ID Number: Group Number:

Name of policy holder:

Policy holder’s relationship to the patient:

Policy holder’s birthdate:

Policy holder’s employer:

Insurance company:

Address:

Phone number and/or insurance company website:

Scheduled appointment date:

Verification of Eligibility and Benefits by:

Electronic Fax Verbal

Verification scanned, Saved or written in record date:

Maximum Benefits/Year: $

Deductible amount: $

Has deductible been met? Yes No

Does deductible apply to preventive services? Yes No

Determine frequency of preventive services: Twice per year Once every six 6 months

Other

Date of last radiographs:

Prior tooth loss restrictions:

Any other restrictions or limitations:

Benefits remaining for benefit year:

Additional information:

duplication or distribution by any other party requires the prior written approval of the American Dental Association.

This material is educational only, does not constitute legal advice, and may not satisfy applicable state law.

Changes in applicable laws or regulations may require revision. Contact a qualified lawyer or professional

for legal or professional advice.