Patient Intake Form

Dental Insurance Information
Primary Insurance Company
Insurance Company Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Employee with Insurance

First Name Last Name
SSN
### - ## - ####
Employer
Relationship to Patient
Policy Number
Group Number (if applicable)
Secondary Insurance Company
Insurance Company Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Employee with Insurance

First Name Last Name
SSN
### - ## - ####
Employer
Relationship to Patient
Policy Number
Group Number (if applicable)
I understand that payment is my obligation regardless of insurance or any other third party involvement.
For your convenience, we offer the following methods of payment. Please check the option you prefer:

Cash Check Credit Card
I understand that payment is my obligation regardless of insurance or any other third party involvement.
Responsible Party Signature: ___________________________________ Date:______________

(The signature above will be physically signed when at the dental office.)

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	Yes	No
Do you bleed excessively upon injury?
Are you pregnant?
Have you ever been involved with dental medical legal activity?
Are you allergic to latex?

	Yes	No
A. AIDS
B. Arthritis
C. Asthma
D. Cancer
E. Diabetes
F. Epilepsy
G. Glaucoma
H. Heart Murmur
I. Heart Problem
J. Hepatitis
K. High Blood Pressure
L. Jaundice
M. Kidney Problems
N. Low Blood Pressure
0. Nervous Breakdown or Psychiatric Therapy
P. Rheumatic Fever
Q. Stroke
R. Sexually Transmitted diseases
S. Tuberculosis
T. Other Diseases

	Yes	No
Bad breath
Bleeding gums
Blisters on lips or mouth
Burning sensation on tongue
Chew on one side of mouth
Cigarette, pipe, or cigar smoking
Clicking or popping jaw
Dry mouth
Fingernail biting
Food collection between the teeth
Foreign objects
Grinding teeth
Gums swollen or tender
Jaw pain or tiredness
Lip or cheek biting
Loose teeth or broken fillings
Mouth breathing
Mouth pain, brushing
Orthodontic treatment
Pain around ear
Periodontal treatment
Sensitivity to cold
Sensitivity to heat
Sensitivity to sweets
Sensitivity when biting
Sores or growths in your mouth

Confidential Patient Information