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*
Cell Phone
Work Phone
Email Address
How would you like to be contacted?*

Email ReminderPhone CallText Reminder
Which dentist would you prefer to see?

Dr. Andrew ScarselloneDr. Klaus ProtzerEither / Doesn’t Matter
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?*

YesNo
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?

YesNo
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:

Bad BreathBleeding GumsBroken FillingsClicking/Popping JawFood Collection Between TeethGrinding or Clenching TeethJaw PainsLoose TeethProblems with FlossingSensitivity when BitingSensitivity Hot/ColdSensitivity Sweet/SourSnoringSores or GrowthsNone of the aboveOther
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?*

YesNo
Please specify the illnesses and/or operations
Are you currently taking any medications?*

YesNo
Please specify any medications you are currently taking
Do you have any allergies?*

YesNo
Please specify any allergies that you have
Please indicate if you have, or have had, any of the following problems:

AllergiesArthritisArtificial JointsArtificial ValvesAsthmaBleeding DisorderBreathing ProblemsCancerDiabetesGoutHeart ProblemsHeart MurmurKidney DiseaseLiver DiseaseLow Blood PressureHigh Blood PressureMalignant HyperthermiaMaterial AllergiesMedication AllergiesMitral Valve ProlapsePacemakerRheumatic FeverSeizures/EpilepsyStrokeSurgical ImplantsThyroid ProblemsTobacco HabitNone of the aboveOther
Please indicate if you have, or have had, any of the following:

HIV or AIDSHepatitis B or CTuberculosisI have had a blood transfusionI have used intravenous drugs and/or cocaineNone of the aboveOther
For women:

I am pregnantI am nursing
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*

I have read and agree to the terms set out above.
Signature
Should be Empty:

Patient Information

Dental Insurance

Dental History

Medical History

Anything else?

Authorization

Terms & Conditions

Cancellation Policy