New Patient Intake Form
Patient Information
Child's Full Name
First Name
Last Name
Preferred Name/Nickname
Date of Birth
Age
Gender
Male
Female
Other
Prefer not to say
Referred by (if applicable)
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Parent/Guardian Information
Primary Contact
First Name
Last Name
Relationship
Mother
Father
Guardian
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth
Social Security Number
Parental Marital Status
Married
Single
Divorced
Separated
Widowed
Secondary Contact
First Name
Last Name
Relationship
Mother
Father
Guardian
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth
Social Security Number
Parental Marital Status
Married
Single
Divorced
Separated
Widowed
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Insurance Information
Primary Dental Insurance
Policy Holder Name
Member ID
Group #
Secondary Dental Insurance
Policy Holder Name
Member ID
Group #
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Medical History
Primary Physician
Current Medications
Allergies
Up to date of immunizations?
Surgical/Hospitalization History
Type a question
Medical Conditions
ADHD/ADD
Anemia
Anxiety
Asthma/Breathing difficulties
Autism Spectrum Disorder
Behavioral Problems (ODD/PDD)
Blindness
Bleeding disorder (Hemophilia, von Willebrand)
Cancer
Cardiac disease/defects
Cerebral Palsy
Cleft lip/Palate
Depression
Developmental delay
Diabetes
Down Syndrome
Exzema/Skin rash
Hearing loss/difficulties
Intellectual disability
Kidney Disease
Seizures/Epilepsy
Speech Problems
Other
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Dental History
Reason for today's visit
First dental visit?
Yes
No
If no, previous dentist
History of dental trauma?
Yes
No
If yes, please describe
Past treatment (fillings, crowns, extractions)
Yes
No
If yes, please describe
Fluoride toothpaste?
Yes
No
If no, what do they use?
Flossing
Yes
No
Oral Habits
Thumbsucking
Finger sucking
Pacifier
Nail biting
Grinding/Clenching
Nursing/Bottle
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Authorization & Consent
I certify the above information is accurate to the best of my knowledge. I authorize the dental team to perform necessary diagnostic procedures and treatment. I authorize billing of my dental insurance and consent to communication with my child’s healthcare providers as needed. I acknowledge that I have reviewed the practice’s Notice of Privacy Practices (HIPAA).
Signature
Date
-
Month
-
Day
Year
Date
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