Patient Intake Form

PATIENT REGISTRATION

I. PATIENT INFORMATION
Patient Full Name:

First NameLast Name
Gender:

MaleFemaleOther
Date of Birth:

MonthDayYear
Health Care Number (Patient):
Personal Health Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
example@example.com
Home Phone Number:

Area CodePhone Number
Cell Phone Number:

Area CodePhone Number
Referring Dentist:

NamePhone Number
Family Physician:

NamePhone Number
II. IF PATIENT IS A MINOR
Is the patient a minor?

Yes, the patient is a minor.No, the patient is not a minor.
Parent Name / Legal Guardian:

First NameLast Name
Relationship with Patient:
Parent/Guardian/Etc
Phone Number:

Area CodePhone Number

INSURANCE INFORMATION

III. Primary Dental Plan -- (If you do not have this information, please contact your employer or dental office to provide you with it.)
Policy Handler's Name:

First NameLast Name
Employer:
Date of Birth:

MonthDayYear
Insurance Co. Name:
Certificate/ID #:
Group Policy #:
Plan %:
Dependant #:
INSURANCE INFORMATION

Secondary Dental Plan
Do you have a Secondary Dental Plan?

Yes, I have one.No, I do not have one.
Policy Handler's Name:

First NameLast Name
Date of Birth:

MonthDayYear
Employer:
Insurance Co. Name:
Group Policy #:
Certificate/ID #:
Plan %:
Dependant #:

Consent

I, the undersigned, certify that all of the medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted information. I also consent to my physician being contacted if necessary to obtain information that is required for my care. By checking the box below and typing my name below, I am electronically signing this consent form.
PATIENT, PARENT, OR LEGAL GUARDIAN SIGNATURE
I, full name , state that all the answers given in this consent form are truthful.
DATEMonth/Day/Year SIGNATURE Signature
Should be Empty:

PATIENT REGISTRATION