PATIENT INTAKE FORM

PATIENT INTAKE FORM
You must be the Legal Guardian of the patient, or the patient (If 18+ years old). Others may not fill out this form.

You will need the following ready to complete this form:
- Physical copies or images of Insurance card(s)
- Physical copy of state identification (driver's license)
- Primary dental office information (Name of office and practice telephone number)
- Personal information (Patient and or parent's Date of Birth, Social Security Number, address, etc)
Is the Patient 18 years or older?*

Yes (Patient is an Adult, 18+)No (Patient is a minor under the age of 18)
Which office location do you prefer to be seen at?*
LEGAL GUARDIAN INFORMATION

Personal information for the legal Guardian of the Patient
Guardian Name*

First NameLast Name
Guardian Email*
example@example.com
Guardian Mobile/Cell Phone*
Please enter a valid phone number.
Guardian Address*

Street Address

Street Address Line 2

CityState

Zip Code
Guardian Birth Date*

MonthDayYear
Date
What is your relationship to the Patient?*
Please upload a copy of the Legal Guardian's ID/ Driver's License (Front)

PATIENT INFORMATION

Personal Information for the patient
Contact details and Information
Patient Name*

First NameLast Name
Email*
example@example.com
Mobile Phone Number (Use Guardian Phone number if N/A)*
Please enter a valid phone number.
Does the Patient live at the same address as the Guardian?*

YesNo
Patient Address*

Street Address

Street Address Line 2

CityState

Zip Code
Patient Birth Date*

MonthDayYear
Date
Patient Gender*
Today's date*

MonthDayYear
Date
Age*
Please upload a copy of the Patient's ID/ Driver's License (Front).**You may disregard this if the patient is a minor and does not have an ID.

PATIENT INSURANCE INFORMATION
What type of DENTAL Insurance does the patient have?*

Louisiana Medicaid EPSDT MCO Plan (DentaQuest/ MCNA)Single Primary PPO PlanPrimary Insurance + Louisiana MedicaidPrimary and Secondary PPO PlanNone/ Cash

PRIMARY DENTAL INSURANCE

Policy Holder's Information
What is the Policy Holder's Name?*

First NameLast Name
What is the Policy Holder's SSN?*
What is the Policy Holder's Date of Birth?*

MonthDayYear
Date
What is the Policy Holder's Address?*

Street Address

Street Address Line 2

CityState

Zip Code
Who is the Policy Holder's Employer?*
What is the Patient's relationship to the Policy Holder?*
Primary Dental Insurance Policy Information

Information Displayed on the Insurance Card
Insurance Carrier Name*
Subscriber/ Member ID*
Group Number*
What is the Phone number located on the back of the insurance card? (For Providers)*
Please enter a valid phone number.
What is the Address located on the back of the insurance card?*

Street Address

Street Address Line 2

CityState

Zip Code
Please upload a photo of the FRONT of the Primary Dental Insurance policy's insurance card*
Please upload a photo of the BACK of the Primary Dental Insurance policy's insurance card*

SECONDARY DENTAL INSURANCE

Policy Holder's Information
What is the Policy Holder's Name?*

First NameLast Name
What is the Policy Holder's SSN?*
What is the Policy Holder's Date of Birth?*

MonthDayYear
Date
What is the Policy Holder's Address?*

Street Address

Street Address Line 2

CityState

Zip Code
Who is the Policy Holder's Employer?*
What is the Patient's relationship to the Policy Holder?*
Secondary Dental Insurance Policy Information

Information Displayed on the Insurance Card
Insurance Carrier Name*
Subscriber/ Member ID*
Group Number*
What is the Phone number located on the back of the insurance card? (For Providers)*
Please enter a valid phone number.
What is the Address located on the back of the insurance card?*

Street Address

Street Address Line 2

CityState

Zip Code
Please upload a photo of the FRONT of the Secondary Dental Insurance policy's insurance card*
Please upload a photo of the BACK of the Primary Dental Insurance policy's insurance card*

AUTHORIZATION FOR RELEASE OF PATIENT INFORMATION
Referring Dental Office Details
What is the name of the dental office that the patient usually visits?*
Office Telephone Number*
Please enter a valid phone number.
Dentist Name (if known)
Authorization for Release of Patent Information
I, TxAuthorizedPerson hereby authorize the above-named dental office to release the full medical record of Patient to David Ashley MD DMD Oral Surgery Group, PC DBA Oral Surgery and Wisdom Teeth of Louisiana:
I understand that this authorization is voluntary and I may revoke it at any me by notifying the dental office in writing. I also understand that this authorization will expire one year from the date of signing or upon the completion of my treatment, whichever is earlier.

I acknowledge that I have read and understood this authorization and I agree to its terms.
Date*

YearMonthDay
Date
Signature*

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LEGAL GUARDIAN INFORMATION