NEW PATIENT INTAKE FORM
Patient Information
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Preferred Location
Please Select
Bowling Green
South Warren
Russellville
Portland
White House
Date Of Birth
-
Month
-
Day
Year
Date
Age
Gender
SSN
Preferred Name
Employer
Occupation
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Interests
How did you hear about us?
Social Media
Dentist Referral
Print Ad
Friend/Family Referral
Who can we thank for your referral?
Emergency Contact(s)
Primary Contact Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Patient
Secondary Contact Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Patient
Parent/Guardian Information
IF PATIENT IS A MINOR, PLEASE COMPLETE THIS SECTION
Parent/Guardian 1
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer
Work Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Email
example@example.com
Parent/Guardian 2
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer
Work Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Email
example@example.com
Preferred Point of Contact
Insurance Information
Primary
Policy Holder Name
Date of Birth
-
Month
-
Day
Year
Date
SSN
Relationship to Patient
Insurance Company
Member ID
Employer
Group Number
Insurance Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary
Policy Holder Name
Date of Birth
-
Month
-
Day
Year
Date
SSN
Relationship to Patient
Insurance Company
Member ID
Employer
Group Number
Insurance Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Dental History
Dentist
Last Cleaning
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Has the patient had a prior orthodontic consult or treatment?
Yes
No
When?
Primary Orthodontic Concern
Check all that apply
Other (if not listed)
If you answered "yes" to any of the above, please explain:
Medical History
Please check all that apply now or in the past:
Other (if not listed)
If you answered "yes" to any of the above, please explain:
Please list all current medications, dosages, & reason:
Submit
Should be Empty: