New Patients Intake Form | Family Dentistry in Maple

We are pleased to welcome you to our practice, and hope to provide you, your family, relatives and friends with the highest quality of dental care.

In order to render the best professional care it is necessary that we become acquainted with the vital information related to each patient. Of course all information is strictly confidential. We appreciate your cooperation in filling out this form carefully and accurately.

A parent or guardian will be responsible for decisions on my treatment: Yes | No

Emergency Contact:

Phone Number:

Family Doctor:

Phone Number:

Referring Doctor:

Phone Number:

INSURANCE INFORMATION

Methods of Payment

Cash
Debit
VISA
Mastercard
Insurance

Person Responsible for Payment

Self
Spouse
Parent/Guardian
Other

Do you have Dental Insurance?* Yes | No If yes, please fill in the following insurance information. Otherwise, skip this section.

Policy Holder's Name:

Insurance Year End: (usually Dec. 31)

Policy Holder's Name:

Insurance Year End: (usually Dec. 31)

Medical History

Please select yes or no to the following:

Are you presently being treated by a physician?*

If yes, please specify:

Are you taking any medications, pills, drugs, or medicine?

If yes, please list:

Do you suffer from any allergies (hay fever, latex, etc)?

If yes, to what?:

Allergies: Have you ever had a reaction to any of the following?*

Have you ever been warned against using any other medications?

If yes, please specify:

Have you ever taken prolonged medical or non-medical drugs?

If yes, please specify:

Do you bruise easily or have prolonged bleeding?

Have you ever fainted, had shortness of breath, or chest pains?

Do you smoke?

If yes, how many per day?:

Women, are you currently pregnant?

If yes, when are you due?:

Are you using birth control?

Do you have any of the following:

CHILDREN: Have you recently had any of the following (approximate date)?

Chicken Pox Measles Mumps
Strep Throat Tonsillitis None

Is there anything else we should know about your health?

Dental History

What is the reason for this visit? Emergency Examination Cleaning Other:

How frequently do you see your dentist? Every 3-6 months Annually Other:

Date of your last dental visit?

Date of your last X-Ray?

How often do you brush per day?

How often do you floss per day?

General Release:

I understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I have completed is correct and I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care provider as requiredx by this dental office. I authorize this dental office to perform diagnostic procedures as may be requiredx to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependants. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.

Family Dentistry in Maple Medical History Form

PATIENT INFORMATION

CONTACT INFORMATION

INSURANCE INFORMATION

Medical History

Dental History

FAMILY DENTISTRY IN MAPLE

VISIT US - OPEN 7 DAYS A WEEK

LOCATION

Through Fundraising Efforts Family Dentistry in Maple Are Proud Sponsors Of: