Patient Intake and Consent Form

Patient Intake and Consent Form

Please complete all sections. This form collects your medical, dental, and consent information for your care and HIPAA compliance.
Patient Information
Patient Name*

First NameLast Name
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Preferred Pharmacy
Preferred Pharmacy Name
Preferred Pharmacy Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Pharmacy Address
Medical Background
Date of Birth (mm/dd/yyyy)*

MonthDayYear
Age*
Gender*
Height (inches)*
Weight (lbs)*
YesNo
YesNo
YesNo
Please list other current medications you are taking. Include name, reason, dosage, frequency, and last time taken (prior to surgery):
Heart FailureHeart DiseaseHeart Attack (If Yes, what year?)Heart ProblemsGlaucomaTobacco ProductsDrug AddictionKidney TroubleNot ApplicableOther
YesNo
If yes, please provide current A1C and date of last A1C test:
YesNo
YesNo
YesNoOther
YesNo
If Yes, Date started using (mm/dd/yyyy):

MonthDayYear
Date
Anticoagulants/Blood ThinnersAspirinCodeine or other narcoticsIodineIbuprofen/TylenolSteroidsTranquilizersNot ApplicableOther medication(s)
Medical History
Date of last physical exam (mm/dd/yyyy)

MonthDayYear
Date
Physician's Name
Physician's Phone
Please enter a valid phone number.Format: (000) 000-0000.
Previous Dentist's Location
YesNo
YesNo
YesNo
YesNo
Chest PainsHeart FailureHeart DiseaseHeart ProblemsDepressionCongenital Heart DiseaseLiver DiseaseHypertensionHeart MurmurRheumatic FeverAnxietySickle Cell DiseaseSinus TroubleArtificial JointsThyroid DiseaseAnemiaBlood TransfusionsMitral Valve Prolapse (MVP)Inflammatory RheumatismShortness of BreathUlcersMental Health IssuesEmphysemaFainting/DizzinessEating DisorderEpilepsy/SeizuresPersistent CoughTuberculosisAsthmaHepatitis AHepatitis BHepatitis C or DPacemakerNight SweatsStrokeNot ApplicableOther
Women’s Health
YesNoN/A
YesNo
YesNo
YesNo
Allergies
Local AnestheticPenicillinCodeineLatexAcrylicMetalsSulfa DrugsIodineSleeping PillsBarbituratesAspirinSedativesAntibioticNot ApplicableOther
Additional medical, dental, and consent fields (continued as per PDF, including all checkboxes, radio buttons, textboxes, dates, and signature fields, mapped exactly to the PDF layout)
Patient/Parent/Guardian Signature*
Should be Empty:

Patient Intake and Consent Form

Patient Information

Preferred Pharmacy

Medical Background

Medical History

Women’s Health

Allergies