NEW PATIENT INTAKE FORM
Contact Information
Name:
*
First Name
Middle Initial
Last Name
Birthdate:
*
-
Month
-
Day
Year
Date Picker Icon
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home phone:
Format: (000) 000-0000.
Cell phone:
Format: (000) 000-0000.
Work phone:
Format: (000) 000-0000.
Email:
*
example@example.com
NAME
PHONE NUMBER
*
Emergency contact:
First Name
Last Name
Relationship to patient:
Daytime phone:
Format: (000) 000-0000.
Cell phone:
Format: (000) 000-0000.
Insurance Information
Policy Holder:
First Name
Last Name
Birthdate(M/D/Y):
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to patient:
Phone:
Format: (000) 000-0000.
Insurance company:
Employer:
Group/Policy #:
Certificate/Div/ID #:
Policy Holder:
First Name
Last Name
Birthdate(M/D/Y):
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to patient:
Phone:
Format: (000) 000-0000.
Insurance company:
Employer:
Group/Policy #:
Certificate/Div/ID #:
Referral Information
NAME: (Circle: Friend / Relative / Doctor / Specialist)
First Name
Last Name
Circle
Friend
Relative
Doctor
Specialist
How did you hear about us?
Google
Other search engine
Facebook
Instagram
Other
Communication
I authorize Cypress Dental to contact me via email and SMS. (✓):
YES
NO
Preferred method of contact (✓):
Home
Cell
Work
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MEDICAL HISTORY
1. What is your estimate of your general health?
Excellent
Good
Fair
Poor
2. Are you presently receiving any treatment for any illness (i.e., osteoporosis, cancer, upcoming surgeries, developmental delays)?
YES
NO
If yes, please provide details:
3. Do you currently smoke?
YES
NO
Have you ever been a smoker?
YES
NO
If yes, please provide details (i.e., tobacco, marijuana):
4. Have you had any of the following: prosthetic heart valve replacement, heart transplant, congenital heart disease, infective endocarditis?
YES
NO
If yes, has your doctor instructed you to take pre-medications before dental treatment?
YES
NO
NOT SURE
5. Are you taking any medication or non-prescription drugs?
YES
NO
If yes, please write their names below or provide our staff with your medication list:
6. Have you ever had a peculiar or adverse reaction to any medicine or injections? (e.g., penicillin, aspirin, local anesthesia, or dental freezing)
YES
NO
If yes, please describe symptoms/reaction:
7. Do you have allergies?
YES
NO
Other
Please indicate (✓) if you presently have or ever had any of the following:
Acid Reflux
Alcohol or substance dependency
Artificial joints / valves
Cancer
Eating disorders
Frequent headaches or earaches
Hepatitis (type)
Hyperglycemia
Kidney disease
Mental or nervous disorder
Radiation therapy
Thyroid problems
Viral infection/cold sores
MALE: prostate disorders
Any lumps or swelling
Anemia
Asthma
Chemotherapy
Epilepsy / seizures
Heart attack
High blood pressure
Hypoglycemia
Liver disease
Pacemaker or implantable defibrillator
Stomach ulcers
Tuberculosis
FEMALE: taking birth control
AIDS/HIV
Arthritis or Rheumatism
Blood transfusion
Diabetes
Fainting/dizzy spells
Head or neck injuries
Low blood pressure
Jaundice
Lung disease/chest pains
Prosthetic joint
Stroke
Tumor / abnormal growth
FEMALE: pregnant
8. Is there any additional information related to your health that has not been addressed above (i.e., past or upcoming surgeries)?
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DENTAL HISTORY
Last Dental Visit:
Or Circle Last Visit
less than 1 year
1- 5 years
over 5 years
What was the reason for your last dental visit?
Did you have any x-rays taken at the last appointment?
YES
NO
If yes, please contact your previous office for your most recent x-rays, including any Panoramic x-rays, and have them send them to info@cypressdental.ca
How often do you visit the dentist?
twice a year
once a year
emergencies only
How often do you brush your teeth in a day?
none
once
twice
three or more times
How often do you floss your teeth?
none
once
twice
three or more times
Please indicate (✓) if you
presently have
or
ever had any
of the following:
Presently Have
Fear of dental treatment
An unfavorable dental experience
Complications from past dental treatment
Disappointment with appearance ofprevious dental work
Difficulty getting numb
Bleeding gums
Sensitive teet
Hot
Cold
Bite
Sweets
Sores, swelling or lumps in your mouth
Head, neck, or jaw injuries
Other issues
Loosening of teeth
Food getting caught between your teeth
Dry mouth or excessive thirst
Burning or itchy sensation in your mouth
Unpleasant odor
Bite your lips or cheeks regularly
Snoring or sleeping disorders
Have you ever had:
Have you ever had:
Orthodontic treatment
Extractions
Prolonged bleeding AFTER extraction
Periodontal (gum) treatment
Oral hygiene instructions
A bite plate or mouth guard
Dentures or partial denture
Implants
Treatment from a specialist
If yes, what type?
Do you experience any of the following problems in your jaw:
Do you experience any of the following problems in your jaw:
Clicking
Pain (ear, joint, or side of face)
Difficulty in opening / closing
Difficulty in chewing
Clenching or grinding
I would like to improve:
I would like to improve:
My smile
The way my teeth look
Dark fillings / tooth
Crowded / crooked / overlapped teeth
Thinning / shortened teeth
Additional comments or concerns?
To the best of my knowledge, all of the preceding answers and information provided are true and correct.
If I ever have any changes in my health, I will inform the dentist at the next appointment.
Patient/Guardian signature
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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We would love to get to know you!
These questions are optional but we appreciate you sharing.
Why did you leave your last dentist:
What kept you from completing your needed dentistry in the past?
Time
Cost
No perceived problem
Other
Is there anything you would like us to know?
OUR MISSION
Our office is committed to providing our patients with a dental experience that will promote a lifelong relationship built on trust, confidence, quality dentistry, and excellent patient care. Here at Cypress Dental, we want to help change the way you feel about going to the dentist. Our specialized equipment, facility and staff are able to address all your dental needs in a relaxed and friendly manner.
OUR OFFICE POLICIES
Fees:
Our fees are based on the quality of material we use and our clinical expertise and experience in performing your needed treatment. At the completion of an appointment payment is expected unless financial arrangements have been made in advance. Our payment options include cash, debit card, e-transfer, Visa, and MasterCard. Cypress Dental requires a minimum of two business days notice if an appointment is to be cancelled or rescheduled. If less than two business days is given, a fee starting from $50 and up will be applied. Fee may be waived based on the situation and appointment length. Please be aware that insurance companies do not cover missed appointment fees.
Insurance:
Our office understands the value of insurance benefits to our patients. We will complete and submit your insurance claims and supply all documentation to maximize your benefits.
Many dental insurance plans allow us to submit claims electronically on your behalf. In order to do this, we require your authorization to speak with your insurance company and release any information pertaining to your claim. Release of information contained in claims submitted electronically to my dental benefits provider. I authorize the communication of information related to dental coverage and benefits to my dental insurance provider. If allowed, I also assign my benefits payable from claims submitted electronically and authorize payment directly to this dental practice.
Patient or parent/guardian signature
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: