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

Patient Information
Date*
Month
Day
Year
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*
Month
Day
Year
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*
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*
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

Step 1 of 4

Patient Information

Insurance Information

Secondary Insurance Information

Medical History

Office Information

OFFICE HOURS

Dental Services

APPLY FOR CARE CREDIT

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