Intake Form – Online Forms Pro

Medical Information

Are you under the care of a physician now?*

Physician Name

Physician Phone

Last Physical Exam

Do you currently have, or have you ever had any of the following?

Heart Failure*

Hepatitis*

Nervousness / Depression*

Heart Disease / Attack*

Liver Disease*

Psychiatric Treatment*

Chest Pain*

Epilepsy or Seizures*

Multiple Sclerosis*

High Blood Pressure*

Fainting / Dizzy Spells*

Diabetes*

Heart Murmur*

Cancer / Leukemia*

Thyroid Disease*

Mitral Valve Prolapse*

Chemotherapy*

HIV Positive*

Rheumatic Fever*

Glaucoma*

AIDS*

Heart Defects*

Emphysema*

Arthritis*

Scarlet Fever*

Asthma*

Pain in Jaw Joints*

Artificial Heart Valve*

Difficulties Breathing*

Loss of Appetite*

Heart Pacemaker*

Sinus Trouble*

Loss of Sleep*

Heart Surgery*

Severe Allergies / Hives*

Use a C-pap*

Artificial Joints / Prosthesis*

Yellow Jaundice*

Loud Snoring*

Anemia*

Drug Addiction*

Bruise Easily*

Stroke*

Hemophilia*

(Frequent) Cold Sores*

Kidney Disease*

Sickle Cell Disease*

Adverse reaction to local anesthetic (Novacaine)*

Latex Allergy*

Medication Allergies*

List any and all medications that you are knowingly allergic to, or have had an adverse reaction to.

Current Medications*

Please list ALL medications you are currently taking. If you are not taking any medications at this time, please type "none."

Are you pregnant or trying to get pregnant?*

Are you currently taking Birth Control Pills?*

Are you currently taking Blood Thinners?*

Do you smoke?*

How many cigarettes a day do you smoke?*

Because you answered "Yes" above, please tell us here.

Do you use any other nicotine products (Vape, patch, gum, etc.)?*

Do you use any recreational drugs? If so, which ones, and how frequently do you use them?*

Is there any other medical information not included above which we should be informed about?

Additional Medical Information

Because you answered "Yes" above, please tell us here.

Have you ever or do you currently receive Botox® Injections?

Type of Botox® treatment.

Please indicate the nature of your treatment.

Dental Information

Has the fear of discomfort kept you from regular dental visits?*

Are you satisfied with your past dentistry?*

Have you had any bad experiences in a dental office?*

Have you ever had Periodontal Therapy?*

Are you concerned that you may have bad breath?*

Do your gums bleed easily, feel tender or irritated?*

Are your teeth sensitive to hot, cold and/or sweets?*

Are there areas in your mouth where food sticks and/or gets caught?*

Are you self-conscious about the appearance of your teeth?*

Do your jaws often feel tired and/or sore?*

Do you experience excessive headaches and/or neck pain?*

Do you experience clicking or popping when opening/closing/chewing?*

Are you aware of yourself clenching or grinding your teeth?*

Have you ever had Orthodontic Treatment (Braces)?*

What prompted you to seek dental care at this time?*

Approximately how long has it been since your last dental examination & cleaning?*

What, if anything would you do to change the appearance of your teeth? (Check all that apply)

Whiter
Straighter
Longer
Shorter
Shaped Differently
I would not change anything

Consent

I acknowledge that all of the above information is accurate to the best of my knowledge. I authorize this office and its trained staff to take x-rays & other diagnostic aids needed to make proper diagnosis of my dental needs. I authorize this office and its trained staff to perform all forms of treatment, as is indicated. I understand the use of anesthetic agents will be used when indicated & that this embodies a certain risk. I give my permission to release medical/dental information as needed to process insurance claim forms or to receive proper treatment from other health providers.

Signature of Patient / Parent or Guardian*

Entering your name above constitutes your signature to proceed.

By entering my name above and checking this box, I consent to give this information.*

I consent.

Please fill out the form below.

Contact Information

Relationship Information

Dental Insurance Information

Medical Information

Do you currently have, or have you ever had any of the following?

Dental Information

Consent

Financial Agreement

FINANCIAL AGREEMENT

INSURANCE FILING

ASSIGNMENT OF INSURANCE BENEFITS

DELINQUENT ACCOUNTS

COLLECTION PROCEEDINGS

FAILED APPOINTMENTS

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

FOR MEDICARE ELIGIBLE PATIENTS ONLY