NEW - New Patient Intake Form

Patient legal name*

First NameLast Name

Patient chosen name

Email of person completing this form*

You will be able to save and continue this form at a later time.

Mobile number of person completing this form

Please enter a valid phone number.

Prior to scheduling the screening appointment we will need either a Referral from a Dentist for Treatment under GA with Xrays OR a Letter of Necessity from Primary Care Physician. See links below to download forms. *

Click either link below to download our form, or attach documents from your provider:

IF YOU HAVE QUESTIONS REGARDING THE REFERRAL PROCESS, PLEASE CALL 267-639-6250.

Gender patient identifies with

MaleFemaleOther

Patient sex at birth

MaleFemale

Patient preferred pronouns

She/HerHe/HimThey/ThemOther

Patient date of birth*

Date

Patient social security number*

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Height*

Patients with a BMI 45 or higher or a weight of 300 lbs or higher are not candidates in our outpatient setting.

Weight*

What language do you and the patient best understand?*

Medicaid insurance*

PANJPrivate Pay

Name of state Medicaid plan (Examples: Liberty (Aetna, Fidelity, Wellpoint), United Healthcare, Horizon, etc.)*

Insurance policy number*

Does the patient have dental insurance provided by a family member's employer?*

YesNo

Name of employer based insurance (Examples: Delta Dental, MetLife, etc.)

Insurance policy number*

Insurance subscriber name*

First NameLast Name

Insurance subscriber social security number*

Insurance subscriber date of birth*

Insurance subscriber relationship to patient *

Please upload a copy of the front and back of your insurance card(s)

Referral obtained from*

Patient residence*

Family HomePermanent Supportive Housing

Name of permanent supportive housing program*

Name of primary caregiver*

First NameLast Name

Primary caregiver phone number*

Cell phone number preferred

Primary caregiver email*

example@example.com

Name of legal guardian/person who signs consent *

First NameLast Name

Relationship to patient

Legal guardian phone number*

Cell phone number preferred

Legal guardian email*

example@example.com

Is the patient edentulous (without teeth)?*

YesNo

Date of last dental exam

Date

Is the patient cooperative with the following dental care? Check all that apply.*

ExamCleaningX-rays (please provide most recent)None of the above

Is the patient currently experiencing dental pain or discomfort?*

YesNoNot sure

Does the patient's gums bleed when brushing or using dental floss?*

YesNoNot sure

Does the patient have earaches or neck pains?*

YesNoNot sure

Has the patient ever had orthodontic (braces) treatment?*

YesNoNot sure

Has the patient had their wisdom teeth removed?*

YesNoNot sure

What year were their wisdom teeth removed? *

Does the patient brux or grind their teeth?*

YesNoNot sure

Does the patient have sores or ulcers in their mouth?*

YesNoNot sure

Does the patient wear dentures or a partial?*

YesNoNot sure

Has the patient ever had a serious injury to their head or mouth?*

YesNoNot sure

List all medical diagnosis/conditions *

Example: IDD, Down Syndrome, etc.

List any allergies and reactions *

List all current medications including vitamins, supplements, THC, CBD, weekly or monthly injections*

If preferred, you can attach a medication list at the end of this form

How are oral medications administered?*

Has the patient been hospitalized in the past year?*

YesNo

If yes, when? and what was the illness or problem?*

Please attach documentation from hospitalization

List any surgeries/operations and what year performed*

Does the patient see any Specialty Health Care Provider(s)? Please list the type of specialty, and date of last visit *

Examples: Cardiologist, Neurologist, etc.

Has the patient ever had general anesthesia?*

YesNo

Has the patient or any family member had any complications with general anesthesia?

Does the patient have seizures?*

YesNo

Date of last seizure *

Date

Any anti-seizure medication changes in the last 2 months?*

YesNo

Does the patient have a CPAP machine?*

YesNo

Please indicate if you have or have not had any of the following diseases or problems*

	Yes	No	Not Sure
Abnormal bleeding
Adrenal Disease
AIDS or HIV infection
ALS
Anemia
Angina
Aortic Stenosis
Arrhythmia
Arteriosclerosis
Arthritis
Artificial (prosthetic) heart valve
Asthma
Atrial Septal Defect
Autoimmune disease
Blood transfusion
Bronchitis
Cancer/Chemotherapy/Radiation Treatment
Cardiovascular disease
CHD: Repaired (completely) in last 6 months
CHD: Repaired CHD with residual defects
Chest pain upon exertion
Chiari Malformation
Chronic Aspiration
Chronic or recent Acute Pancreatitis
Chronic pain
Congenital heart disease (CHD): Unrepaired, cyanotic CHD
Congestive heart failure
Coronary Artery Disease
Damaged heart valves
Damaged valves in transplanted heart
Deep brain stimulator
Diabetes Type I or II
Dialysis
Eating disorder
Emphysema
Excessive urination
G.E. Reflux/persistent heartburn
Gastrointestinal disease
Glaucoma
Heart attack
Heart murmur
Hemophilia
Hepatitis, jaundice or liver disease
High blood pressure
Huntington’s Disease
Insulin pump
Kidney problems
Low blood pressure
Malnutrition
Mental health disorders
Mitochondrial disease
Mitral valve prolapse
Multiple Sclerosis
Myotonic Dystrophy
Neurological disorder
Night sweats
Osteoporosis
Other congenital heart defects
Pacemaker
Persistent swollen glands in neck
Pituitary disease
Pneumonia in past three months
Previous ineffective endocarditis
Pulmonary Hypertension
Recurrent Infections
Rheumatic fever
Rheumatic heart disease
Rheumatoid arthritis
Severe headaches/migraines
Severe or rapid weight loss
Sexually transmitted disease
Sickle Cell Disease
Sinus trouble
Sleep disorder
Stroke
Systemic lupus erythematosus
Thrombocytopenia
Thyroid problems
Tracheostomy
Tuberculosis
Tubuerous Sclerosis
Ulcers
Ventricular Septal Defect
VNS Implant
Von Willebrand Disease

Is there anything else you want our dentists and anesthesiologists to know?

Please attach any additional relevant documentation such as Lifetime Medical History, dental x-rays, or any recent hospitalization records.

New Patient Intake/Health History Form