Patient Intake Form (Mountain)

Patient First Name
Patient Last Name
Patient Common Name (if any)
Home Address*
Street
City*
Postal Code*
Phone Number*
Please enter a valid phone number.
Email Address*
Patient Date Of Birth*

MonthDayYear
Patient Age*
Patient Sex*
Patient Preferred Pronoun

Are you completing this form on behalf of a dependent child?*
The following is requested so that we can communicate properly with the people involved in your child’s treatment.
Parents are...*
Child lives with...*
Please advise who the child lives with*
Responsible Party #1 — Details
Responsible Party #1 — Name*

First NameLast Name
Responsible Party #1 — Address*
Street
Responsible Party #1 — City*
Responsible Party #1 — Postal Code*
Responsible Party #1 — Email*
Responsible Party #1 — Mobile Phone*
Responsible Party #1 — Home Phone
Responsible Party #1 — Date Of Birth*

MonthDayYear
Would you like to add Responsible Party #2 details?*
Responsible Party #2 — Details
Responsible Party #2 — Name*

First NameLast Name
Responsible Party #2 — Address*
Street
Responsible Party #2 — City*
Responsible Party #2 — Postal Code
Responsible Party #2 — Email*
Responsible Party #2 — Mobile Phone*
.
Responsible Party #2 — Home Phone
Responsible Party #2 — Date Of Birth*

MonthDayYear
Are there any other adults we should know about?*
Other Adult #1 — Name

First NameLast Name
Other Adult #1 — Relationship To Patient
Other Adult #1 — Mobile Phone
.
Other Adult #1 — Home Phone
Other Adult #2 — Name

First NameLast Name
Other Adult #2 — Relationship To Patient
Other Adult #2 — Mobile Phone
.
Other Adult #2 — Home Phone
.

The following is requested so that we can assist in determining any qualifying insurance coverage for Orthodontics.
Do you or another adult in the family have insurance coverage?*
Insured Party #1 — Name*

First NameLast Name
Insured Party #1 — Relationship To Patient*
ie. Mother, Father, Step-Mother, Step-Father
Insured Party #1 — Birth Date*

MonthDayYear
Insured Party #1 — Policy or Group #*
.
Insured Party #1 — Certificate or ID #*
.
Insured Party #1 — Name of Insurance Company*
Insured Party #1 — Coverage Total ($)
.
Insured Party #1 — Coverage Percentage (%)
.
Is there another adult in the family that has insurance coverage?*
Insured Party #2 — Name*

First NameLast Name
Insured Party #2 — Relationship To Patient*
ie. Mother, Father, Step-Mother, Step-Father
Insured Party #2 — Birth Date*

MonthDayYear
Insured Party #2 — Policy or Group #*
.
Insured Party #2 — Certificate or ID #*
.
Insured Party #2 — Name of Insurance Company*
Insured Party #2 — Coverage Total ($)
.
Insured Party #2 — Coverage Percentage (%)
.
Is there another adult in the family that has insurance coverage?*
Insured Party #3 — Name

First NameLast Name
Insured Party #3 — Relationship To Patient
ie. Mother, Father, Step-Mother, Step-Father
Insured Party #3 — Birth Date

MonthDayYear
Insured Party #3 — Policy or Group #*
.
Insured Party #3 — Certificate or ID #*
.
Insured Party #3 — Name of Insurance Company
Insured Party #3 — Coverage Total ($)
.
Insured Party #3 — Coverage Percentage (%)
.
Is there another adult in the family that has insurance coverage (private or public)?*
Insured Party #4 — Name

First NameLast Name
Insured Party #4 — Relationship To Patient
ie. Mother, Father, Step-Mother, Step-Father
Insured Party #4 — Birth Date

MonthDayYear
Insured Party #4 — Policy or Group #*
.
Insured Party #4 — Certificate or ID #*
.
Insured Party #4 — Name of Insurance Company
Insured Party #4 — Coverage Total ($)
.
Insured Party #4 — Coverage Percentage (%)
.

Please tell us how you arrived at our office?*

Family DentistGoogle Searchdocbraces WebsiteSocial Media Post (ie Facebook, Instagram, Tik Tok)Invisalign WebsiteOther AdvertisementA Family Member Is Being/Has Been Treated HereA Friend Who Had/Has Treatment HereOther
Please specify name*
We love to thank our patients for their referrals!

RELEASE OF INFORMATION:

I consent to the taking of x-rays, photographs and other necessary records before, during and after treatment for the purposes of planning, performing and evaluating treatment.

I grant permission for Mountain Orthodontics to share pertinent information with other medical, dental, and insurance professionals as it relates to the patient’s orthodontic treatment and overall dental care.

I authorize release of information from my insurance company as it relates to the patient’s dental/orthodontic claims, benefits, pre-determinations and coverage.

To the best of my knowledge, I have answered all questions accurately and truthfully. I understand that providing incorrect information may be dangerous to the patient’s health. I also agree to inform the Orthodontist and/or staff member of any changes in the patient’s medical status or other pertinent information.
Signature of Patient or Responsible Party*

Clear
Today's Date*

MonthDayYear
Date

Sender Name
PLEASE SUBMIT THE FORM BY CLICKING THE BUTTON BELOW

We can't wait to start you on your smile journey!

This form is HIPPA Compliant
Should be Empty:

Responsible Party #1 — Details

Responsible Party #2 — Details