Hygiene in Motion Intake & Consent Form 📋✨

Hygiene in Motion Intake & Consent Form 📋✨

Please fill out all required fields accurately to help us provide personalized dental hygiene services.
Patient Information
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Physician Information
Physician Name

First NameLast Name
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Last Medical Exam

MonthDayYear
Date
Insurance Information
Primary Insurance Provider Name
Primary Policy Number
Primary Subscriber Name

First NameMiddle NameLast Name
Primary Subscriber Date of Birth

MonthDayYear
Date
Primary Insurance Card Photo(s)

Cancelof
Secondary Insurance Provider Name
Secondary Policy Number
Secondary Subscriber Name

First NameMiddle NameLast Name
Secondary Subscriber Date of Birth

MonthDayYear
Date
Secondary Insurance Card Photo(s)

Cancelof
Medical History
Medical conditions

Other
If other, please specify
Medications and Allergies
Are you currently taking any medications?
List your current medications
Medication allergies
Other allergy categories

Other
Please describe any allergies or reactions
Dental and Myofunctional History
Date of Last Dental Cleaning

MonthDayYear
Date
Current Oral Symptoms
Do You Have Any Oral Habits?
If Yes, Please Describe Oral Habits
Is Your Tongue Typically Resting on the Roof of Your Mouth?
Do You Frequently Breathe Through Your Mouth?
Do You Have Speech Concerns?
Do You Have Swallowing Concerns?
Please Describe Any Speech or Swallowing Concerns
Additional Dental or Myofunctional Concerns
Consent, Acknowledgment, and Signatures
Consent to Dental Hygiene Services

Other
Consent to Additional Services
Risks and Understanding Acknowledgment Please Initial
Consent for Mobile Care Services
Medical Responsibility Acknowledgment
Privacy and Health Information Consent
Insurance and Payment Policy Acknowledgment
Cancellation Policy Acknowledgment
Patient Electronic Signature and Date
Medical History Accuracy Declaration Signature and Date
Should be Empty:

Hygiene in Motion Intake & Consent Form 📋✨

Patient Information

Physician Information

Insurance Information

Medical History

Medications and Allergies

Dental and Myofunctional History

Consent, Acknowledgment, and Signatures