New Patient Intake Form

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form completely. If you have questions we will be glad to help you. We look forward to working with you in maintaining your dental health.

Step 1 of 4

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Patient Information
Date*
MM
DD
YYYY
Name*
First Last
Email*
Enter Email Confirm Email
Home Phone*
Address*
Street Address City State ZIP Code
Cell Phone*
SSN#*
Ex. 123-45-6789
Birth Date*
MM
DD
YYYY
Sex*
Age*
Patient Employed By:
Occupation
Business Address
Street Address City State ZIP Code
Business Phone
Whom may we thank for referring you?
In case of an emergency, who should be notified?*
Emergency Contact's Phone Number*

Insurance Information
Do you have insurance?*
- No
- Yes
Name of person responsible for account*
First Last
Relation to patient*
Account holder birth date*
Date Format: MM slash DD slash YYYY
Account holder SSN#*
Address (if different from patient)
Street Address City State ZIP Code
Person Responsible Employed by:
Occupation
Employer Address
Street Address City State ZIP Code
Employer Phone Number
Insurance Company*
Contract Number
Group Number
Insurance Phone Number

Secondary Insurance Information
Is patient covered by secondary dental insurance?
Subscriber Name*
First Last
Relation to patient*
Account holder birth date*
Date Format: MM slash DD slash YYYY
Account holder SSN#*
Address (if different from patient)
Street Address City State ZIP Code
Person Responsible Employed by:
Occupation
Employer Address
Street Address City State ZIP Code
Employer Phone Number
Insurance Company
Contract Number
Group Number
Insurance Phone Number
Names of other dependents covered under the plan

Medical History
Physician's Name
First Last
Physician's Phone
Physician's Address
Street Address City State ZIP Code
Former dentist's name
First Last
Former dentist's address
Street Address City State ZIP Code
Fomer dentist's phone
Have you ever taken antibiotics prior to a dental appointment?
- Yes
- No
Do you feel very nervous about having dental treatment?
- Yes
- No
Have you ever had a bad experience at a dentist's office?
- Yes
- No
Has your heart rate ever increased after an injection? (felt jittery or shaky)
- Yes
- No
Are you having pain or discomfort at this time?
- Yes
- No
Have you ever broken a bone in the last 2 years?
- Yes
- No
Have you been a patient at a hospital during the last 2 years?
- Yes
- No
Have you been under the care of a medical doctor during the last 2 years?
- Yes
- No
Have you taken any medication or drugs during the last 2 years?
- Yes
- No
Please list the medications you have taken
Are you allergic (i.e. itching, rash, swelling of hands, feet and eyes) or made sick by anything?
- Yes
- No
Please list what you have allergic reactions to
Have you ever had any excessive bleeding requiring special treatment?
- Yes
- No
Have you ever taken any of the group of drugs referred to as "fen-phen"
- Yes
- No
These include combinations of Ionimin, Adipex, Fastin (phentermine), Pondimim (fenfluramine) and Redux(dexfenfluramine).
Please select any of the following you have had or have at the present
Organ Transplant*
- Yes
- No
Congenital Heart Disease*
- Yes
- No
Heart Failure*
- Yes
- No
Heart Disease or Failure*
- Yes
- No
Rheumatic Fever*
- Yes
- No
Heart Murmur*
- Yes
- No
Artificial Heart Valve < 6 Mos.*
- Yes
- No
Hemodialysis*
- Yes
- No
Heart Surgery*
- Yes
- No
Mitral Valve Prolapse*
- Yes
- No
Artificial Joint < 2yrs*
- Yes
- No
Previous Endocarditis*
- Yes
- No
Emphesyma*
- Yes
- No
Tuberculosis (TB)*
- Yes
- No
Asthma*
- Yes
- No
Cancer*
- Yes
- No
Thyroid Disease*
- Yes
- No
Athritis Rheumatism*
- Yes
- No
High Blood Pressure*
- Yes
- No
Stroke*
- Yes
- No
Heart Pacemaker*
- Yes
- No
AIDS / HIV*
- Yes
- No
Hepatitis*
- Yes
- No
Liver Disease*
- Yes
- No
Diabetes*
- Yes
- No
Epilepsy of Seizures*
- Yes
- No
Kidney Disease*
- Yes
- No
Anemia*
- Yes
- No
Glaucoma*
- Yes
- No
Angina Pectoris*
- Yes
- No
Hemophilia*
- Yes
- No
Cold Sores*
- Yes
- No
Yellow Jaundice*
- Yes
- No
Fainting or Dizzy Spells*
- Yes
- No
Chemotherapy / Radiation*
- Yes
- No
Sickle Cell Disease*
- Yes
- No
Congenital Heart Lesions*
- Yes
- No
Pain in Jaw Joints*
- Yes
- No
Do you grind your teeth at night?
- Yes
- No
Do you like the appearance of your teeth?
- Yes
- No
Do you like the color of your teeth?
- Yes
- No
Do you have a history of TMJ?
- Yes
- No
(For Women) Are you pregnant?
- Yes
- No
(For Women) Are you taking birth control pills?
- Yes
- No
I authorize my insurance company to pay to the dentist or the dental group all insurance benefits otherwise payable to me for services rendered. I authorize the use of this acknowledgement or signature on all insurance submissions. I authorize the dentist to release all infomation necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance. I further understand that a finance charge of 1.5% (18% annually) will be added to any balance over 60 days. In the event of default I (we) promise to pay legal interest on the indebtedness, together with such collection costs and reasonable attorney fees as may be required to effect collection of this note.
- I Agree
You must select "I Agree" to submit this form. Payment is due in full for treatment unless other arrangements are made.

Office Information

Ackerman & Towson Dentistry
100 Cortona Way Suite 200
Brentwood CA 94513
925-684-7722

OFFICE HOURS

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

8am to 5pm
7am to 4pm
11am to 7pm
9am to 6pm
8am to 5pm
8am to 1pm

Dental Services

Preventive (Oral Disease Prevention)
Cosmetic (Esthetic Treatments)
Restorative (Repairing Teeth)
Periodontics (Gum Treatment)
Orthodontics (Braces)
Dental Implants
Dental Implant Information from AAID

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Step 1 of 4

Patient Information

Insurance Information

Secondary Insurance Information

Medical History