Leaside Dentistry New Patient Intake Form

Name

I prefer to be called

Please Choose

MaleFemaleNon-binaryOther

Preferred Pronouns

Home Address

Postal Code

Home Phone

Work Phone

Ext

Cell Phone

Email

example@example.com

Preferred Method of Contact

Home PhoneWork PhoneCell PhoneEmail

Employer

How did you hear about us?

Previous Dentist

Last visit

Have you ever experienced any problems with dental treatment in the past?

YesNo

Have you ever experienced pain in your jaw joints?

YesNo

Is there anything about your smile that you would like to change?

YesNo

Do your tissues bleed when you brush or floss?

YesNo

Do you snore or have you been diagnosed with sleep apnea?

YesNo

What is your primary concern at this time?

Insurance Company

Group #

Certificate #

Insured's Name

Relation

Insured's Birthdate

Date

Insured's Employer

Insurance Company

Group #

Certificate #

Insured's Name

Relation

Insured's Birthdate

Date

Insured's Employer

Name

Relationship

Phone

Family Physician's Name

Family Physician's Phone

Are you currently being treated for any medical conditions?

YesNoIf yes, please explain:

Are you currently taking any prescription or non-prescription drugs?

YesNoIf yes, please list:

Please select if you currently experience, or have previously experienced any of the following:

Are you taking birth control pills?

YesNo

Are you pregnant?

YesNoIf yes, how many weeks?

Are you nursing?

YesNo

There will be no fee for any rescheduled or cancelled appointments given at least 2 business days' (48 hours) notice, Monday to Friday only (this does not include Saturday and Sunday). long as the office is given at least 48 hours' business days' notice-Monday to Friday only. (This does not include Saturday or Sunday)

It is my responsibility to inform Leaside Dentistry of any changes in my medical status. I authorize the dental staff to perform any necessary dental services during diagnosis and treatment with my informed consent. I authorize photographs to be taken of me and placed in my file as part of my records. I have reviewed the patient consent form regarding collection, use, and disclosure of personal information. It explains how Leaside Dentistry will use my personal information. I know that Leaside Dentistry has a privacy code, and I can ask to see the code at any time. I agree that Leaside Dentistry can collect, use, and disclose personal information about First Name Last Name as set out in the office privacy policy. I authorize release, to my insurance company or plan administrator, the information contained in claims submitted electronically.

I understand that I am responsible for payment of all services, in full, at the time of service to Leaside Dentistry and that payment can be made by cash, debit, visa, mastercard or amex. I am aware Leaside Dentistry will send claims electronically to my insurance company on my behalf and that I will submit secondary claims by mail (if applicable to me).

Full Name

First NameLast Name

Signature of patient or parent/guardian

Date

Leaside Dentistry

DENTAL HISTORY

PRIMARY DENTAL INSURANCE

SECONDARY DENTAL INSURANCE

ALTERNATE CONTACT

FOR WOMEN

CANCELLATION POLICY

CONSENT