New Patient Intake/Health History Form (2026 Update)

  • New Patient Intake/Health History Form

  • In order to complete this form, you will need to upload the following:

    1. Referral from a Dentist OR a Letter of Necessity from Primary Care Physician. See links below to download forms:
      Referral from Dentist for Treatment under GA with Xrays
      OR
      Letter of Necessity from Primary Care Physician
    2. Photos of insurance card, front and back
    3. If the patient lives in supportive housing, include a copy of their Lifetime Medical History (LMH) or Individualized Service Plan (ISP)

    Though not required, please attach any additional relevant documentation such as dental x-rays, or any recent hospitalization records.

    For patient safety and clinical eligibility reasons, Special Smiles is unable to provide treatment for individuals who meet one or more of the following criteria:

    • Weight of 300 lbs or greater
    • Diagnosis of Mitochondrial Disease
    • Diagnosis of Moyamoya Disease
    • Diagnosis of Sickle Cell Disease

    We share this information in advance to help families avoid spending unnecessary time completing intake paperwork it we are unable to safely provide treatment.

    If you have any questions about this form, please call 267-639-6250 prompt #2.

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  • Format: (000) 000-0000.

  • Prior to scheduling the screening appointment we will need either a Referral from a Dentist for Treatment under GA with Xrays OR a Letter of Necessity from Primary Care Physician. See links below to download forms.

    Click either link below to download our form, or attach documents from your provider:

    • Referral from Dentist for Treatment under GA with Xrays 
    • OR
    • Letter of Necessity from Primary Care Physician

    IF YOU HAVE QUESTIONS REGARDING THE REFERRAL PROCESS, PLEASE CALL 267-639-6250.

  • Gender patient identifies with*
  • Patient sex at birth*
  • Patient preferred pronouns*
  • Patient date of birth*
     - -

  • Patients with a BMI 45 or higher or a weight of 300 lbs or higher are not candidates for our outpatient setting.

  • Medicaid insurance*
  • Does the patient have dental insurance provided by a family member's employer?*
  • Insurance subscriber date of birth*
     - -
  • Patient residence*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Is the patient edentulous (without teeth)?*
  • Date of last dental exam*
     - -
  • Is the patient cooperative with the following dental care? Check all that apply.*
  • Is the patient currently experiencing dental pain or discomfort?*
  • Does the patient's gums bleed when brushing or using dental floss?*
  • Does the patient have earaches or neck pains?*
  • Has the patient ever had orthodontic (braces) treatment?*
  • Has the patient had their wisdom teeth removed?*
  • Does the patient brux or grind their teeth?*
  • Does the patient have sores or ulcers in their mouth?*
  • Does the patient wear dentures or a partial?*
  • Has the patient ever had a serious injury to their head or mouth?*

  •  


    We're sorry, but we are unable to see this patient.

    Unfortunatly, patients with a BMI 45 or higher or a weight of 300 lbs or higher are not candidates in our outpatient setting. If you have questions about this policy, please call us at 267-639-6250.

     

  • Has the patient been hospitalized in the past year?*
  • Has the patient ever had general anesthesia?*
  • Does the patient have maternal heritage (mother's side) from Venezuela?*
  • Has the patient or any family member had any complications with general anesthesia?*
  • Does the patient have seizures?*
  • Date of last seizure *
     - -
  • Any anti-seizure medication changes in the last 2 months?*
  • Does the patient have a CPAP machine?*
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