New Patient Intake Form
Patient Information
Name
First Name
Last Name
Preferred Name
Date
-
Month
-
Day
Year
Date
Gender
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Type
Mobile
Home
Email
example@example.com
Responsible Party (if patient is a minor)
Parent/Guardian Name
First Name
Last Name
Relationship to Patient
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Referral
How did you hear about us?
Dental Referral
Friend/Family
Google/Online Search
Social Media
Community Event
Other
If referred by a dentist, please list their name:
Dental and Orthodontic History
What are your main concerns with your teeth or bite?
Have you had orthodontic treatment before?
Yes
No
Do you currently see a dentist?
Yes
No
Dentist's Name
Date of Last Visit
-
Month
-
Day
Year
Date
Insurance Information
Do you have orthodontic insurance?
Yes
No
Insurance Provider
Subscriber Name
Subscriber DOB
-
Month
-
Day
Year
Date
Subscriber Name
Submit
Should be Empty: