Dental New Patient Intake Form
Welcome to Our Practice! Please complete the following information so we may provide you with the best possible dental care.
Patient Information
Full Name:
Date of Birth:
-
Month
-
Day
Year
Date
Age:
Gender:
Male
Female
Other
Social Security #:
Driver's License #:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Preferred Method of Contact:
Phone
Text
Email
Marital Status:
Single
Married
Divorced
Widowed
Employer:
Occupation:
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Emergency Contact
Name:
Relationship:
Phone:
Format: (000) 000-0000.
Responsible Party (If Different From Patient)
Name:
Relationship to Patient:
Phone:
Format: (000) 000-0000.
Address:
Dental Insurance Information
Primary Insurance Company:
Subscriber Name:
Subscriber DOB:
-
Month
-
Day
Year
Date
Employer:
Member ID #:
Group #:
Insurance Phone #:
Format: (000) 000-0000.
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Dental History
Reason for Today's Visit:
Previous Dentist:
Date of Last Dental Visit:
Date of Last Dental X-Rays:
Have you ever experienced any of the following?
Tooth pain or sensitivity
Bleeding gums
Jaw pain or clicking
Grinding or clenching teeth
Bad breath
Loose teeth
Difficulty chewing
Dry mouth
Are you satisfied with the appearance of your smile?
Yes
No
Are you interested in any of the following?
Teeth Whitening
Orthodontics
Veneers
Dental Implants
Cosmetic Dentistry
Medical History
Primary Care Physician:
Physician Phone:
Format: (000) 000-0000.
Date of Last Physical Exam:
Are you currently under a physician's care?
Yes
No
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Are you currently taking any medications?
Yes
No
If yes, please list:
Do you have any allergies to medications or latex?
Yes
No
If yes, please list:
Medical Conditions
Please check any that apply:
Medical Conditions
Heart Disease
High Blood Pressure
Diabetes
Stroke
Cancer
Asthma
Arthritis
Kidney Disease
Liver Disease
Thyroid Disease
Seizures
HIV/AIDS
Blood Disorders
Osteoporosis
Other conditions:
For Female Patients
Are you pregnant?
Yes
No
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If yes, due date:
Habits
Do you use tobacco?
Yes
No
Do you consume alcohol?
Yes
No
Do you grind or clench your teeth?
Yes
No
Consent & Authorization
I certify that the above information is accurate and complete to the best of my knowledge. I authorize the dental team to perform necessary dental treatment and diagnostic procedures. I also authorize my insurance benefits to be paid directly to the dental office.
Patient / Guardian Signature:
Date:
-
Month
-
Day
Year
Date
Randolph Family Dental
Sedation, Cosmetic & Dental Implant Ctr, Fast Braces
3900 FM 3009 Ste 104
Schertz, TX 78154
www.randolphfamilydental.com
Phone:2106589031
Fax: 2106588202
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