Applecross Dental • Intake Form

Patient Information
Name

First NameLast Name
Birthdate

DayMonthYear
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Country
Country (other)
Home/Primary Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Email Address
How would you like to be contacted?
Which dentist would you prefer to see?
Who referred you?
If you found us through our website or other area, we'd love to know!

How nervous are you about seeing the dentist?

	1	2	3	4	5	6	7	8	9	10

1 is Chill, 10 is Scared Stiff

Dental Insurance
Do you have Dental Insurance?
Please fill out the following information and remember to bring your insurance card and insurance details/booklet to your first appointment.
Name of Policy Holder

First NameLast Name
Birthdate of Policy Holder

DayMonthYear
Insurance Company
Employer
Insurance Plan Details
Please include your Group/Plan number and your ID number
Do you have additional/secondary Dental Insurance?
Please fill out the following information and remember to bring your insurance card and insurance details/booklet to your first appointment.
Name of Policy Holder

First NameLast Name
Birthdate of Policy Holder

DayMonthYear
Insurance Company
Employer
Insurance Plan Details
Please include your Group/Plan number and your ID number
Dental History
Former Dentist
What is the approximate date of your last x-rays?
How do you feel about the appearance of your teeth?
Please indicate if you have any of the following problems:

Other
How would you like us to help you today?
Medical History
Physician's Name
Medical Clinic
Have you ever had any serious illnesses or operations?
Please specify the illnesses and/or operations
Are you currently taking any medications?
Please specify any medications you are currently taking
Do you have any allergies?
Please specify any allergies that you have
Please indicate if you have, or have had, any of the following problems:

Other
Please indicate if you have, or have had, any of the following:

Other
For women:
Anything else?
Do you have any additional questions to ask us or information you would like to provide?
Authorization
Terms & Conditions
1. I have reviewed the information on this questionnaire to the best of my knowledge.
2. I understand that this information will be used by my dentist to help determine appropriate dental care.
3. If there is any change in my medical status I will inform my dentist.
4. I authorize the use of this signature on all insurance submissions.
5. I authorize my dentist to release information contained in claims in order to secure the payment of benefits.
6. I hereby assign my dental benefits, payable from claims submitted, to my dentist and authorize payment directly to my dentist.
7. I understand that I am financially responsible for all charges whether or not paid by insurance.
8. I understand that payment is due when service is rendered.
9. I understand that “assignment” (my insurance paying my dentist directly for treatment) is accepted only as a courtesy.
Cancellation Policy

I understand that missed or cancelled appointments are subject to a cancellation fee unless two (2) business days notice is given.
Patient Authorization
Signature
Should be Empty:

Patient Information

Dental Insurance

Dental History

Medical History

Anything else?

Authorization

Terms & Conditions

Cancellation Policy