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.

Additionally, please note that we cannot take patients with a weight of 300lbs or higher.

If you have any questions about this form, please call 267-639-6250 prompt #2.
Please upload all required documents here. *

See links at the beginning of this form if needed.
Cancelof
Patient legal name*

First NameLast Name
Patient chosen name
Name of person completing this form*
Email of person completing this form*
You will be able to save and continue this form at a later time.
Mobile number of person completing this form
Please enter a valid phone number.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:
IF YOU HAVE QUESTIONS REGARDING THE REFERRAL PROCESS, PLEASE CALL 267-639-6250.
MaleFemaleOther
MaleFemale
She/HerHe/HimThey/ThemOther
Patient date of birth*

MonthDayYear
Date
Patient social security number*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What language do you and the patient best understand?*
Height*
Patients with a BMI 45 or higher or a weight of 300 lbs or higher are not candidates for our outpatient setting.
Weight*

PANJPrivate Pay
Name of state Medicaid plan (Examples: Liberty (Aetna, Fidelity, Wellpoint), United Healthcare, Horizon, etc.)*
Insurance policy number*
YesNo
Name of employer based insurance (Examples: Delta Dental, MetLife, etc.)
Insurance policy number*
Insurance subscriber name*

First NameLast Name
Insurance subscriber social security number*
Insurance subscriber date of birth*

MonthDayYear
Insurance subscriber relationship to patient *

Family HomePermanent Supportive Housing
Name of permanent supportive housing program*
Name of primary caregiver*

First NameLast Name
Primary caregiver phone number*
Cell phone number preferredFormat: (000) 000-0000.
Primary caregiver email*
example@example.com
Name of legal guardian/person who signs consent *

First NameLast Name
Relationship to patient
Legal guardian phone number*
Cell phone number preferredFormat: (000) 000-0000.
Legal guardian email*
example@example.com

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.

Rows	Yes	No
Abnormal bleeding
Adrenal Disease
AIDS or HIV infection
ALS
Anemia
Angina
Aortic Stenosis
Arrhythmia
Arteriosclerosis
Arthritis
Artificial (prosthetic) heart valve
Asthma
Atrial Septal Defect
Autoimmune disease
Blood transfusion
Bronchitis
Cancer/Chemotherapy/Radiation Treatment
Cardiovascular disease
CHD: Repaired (completely) in last 6 months
CHD: Repaired CHD with residual defects
Chest pain upon exertion
Chiari Malformation
Chronic Aspiration
Chronic or recent Acute Pancreatitis
Chronic pain
Congenital heart disease (CHD): Unrepaired, cyanotic CHD
Congestive heart failure
Coronary Artery Disease
Damaged heart valves
Damaged valves in transplanted heart
Deep brain stimulator
Diabetes Type I or II
Dialysis
Eating disorder
Emphysema
Excessive urination
G.E. Reflux/persistent heartburn
Gastrointestinal disease
Glaucoma
Heart attack
Heart murmur
Hemophilia
Hepatitis, jaundice or liver disease
High blood pressure
Huntington’s Disease
Insulin pump
Kidney problems
Low blood pressure
Malnutrition
Mental health disorders
Mitochondrial disease
Mitral valve prolapse
Multiple Sclerosis
Myotonic Dystrophy
Neurological disorder
Night sweats
Osteoporosis
Other congenital heart defects
Pacemaker
Persistent swollen glands in neck
Pituitary disease
Pneumonia in past three months
Previous ineffective endocarditis
Pulmonary Hypertension
Recurrent Infections
Rheumatic fever
Rheumatic heart disease
Rheumatoid arthritis
Severe headaches/migraines
Severe or rapid weight loss
Sexually transmitted disease
Sickle Cell Disease
Sinus trouble
Sleep disorder
Stroke
Systemic lupus erythematosus
Thrombocytopenia
Thyroid problems
Tracheostomy
Tuberculosis
Tubuerous Sclerosis
Ulcers
Ventricular Septal Defect
VNS Implant
Von Willebrand Disease